CDC Waiver Form

Instruction: Please fill out all mandatory information from A through K and click the submit button.

A. Type of Request

Type of Humanitarian or emergency request(Required)

Exemption from predeparture testing requirement; and/or

Exception for requirement for proof of being fully vaccinated

B. Personal Information

Name(Required)

(family name/surname, given name)

Passport Number(Required)

Nationality(Required)

C. Contact Number

Cell phone number including country code of passenger or head of household if family unit(Required)

D. Contact E-mail

Email address of passenger or head of household if family unit(Required)

E. Destination Information

U.S. Destination Sddress(Required)

Street Address City State / Province / Region ZIP / Postal Code

Is U.S. destination home address?(Required)

Yes

F. Proposed flight itinerary, including any connecting flights

Airline(Required)

Flight #(Required)

Departure airport and date of departure(Required)

Arrival airport and date of arrival(Required)

G. Vaccination Information

Vaccination Status(Required)

Fully Vaccinated

NOT Fully Vaccinated

Name of vaccine product (or products if a combination)(Required)

Date of first dose(Required)

Date of second dose (if a two-dose series)

PDF or photograph of vaccination record(Required)

Accepted file types: pdf, jpg, gif, png, Max. file size: 5 MB.

H. Purpose of Travel

Purpose of travel to the United States (provide brief explanation of why urgent travel is needed and how travel will contribute to health and safety of passenger(s))(Required)

I. Additional Details

Justification for humanitarian exemption for testing requirement (e.g., no testing available where passenger is located)(Required)

Justification for humanitarian or emergency exception to providing proof of being fully vaccinated (e.g., vaccine availability, passenger ineligible for vaccine at location, insufficient time to become fully vaccinated)(Required)

J. Documentation

Documentation to support justification for exception if provided (e.g., medical records or orders for medical evacuation)(Required)

Drop files here or

Max. file size: 5 MB.

K. Other Information

Information regarding any other solutions that were sought prior to application (e.g., flight changes, testing en route, assistance in obtaining testing/vaccination, etc.)(Required)