中华人民共和国出入境检验检疫

出 入 境 人 员 健 康 检 查 申 请 表

HEALTH EXAMINATION REGISTRATION FORM

申 请 须 知

请仔细阅读下列内容，以便明确自己是否属于法定健康检查对象范围内。凡属于法定健康检查对象，需认真填写申请表，接受检验检疫机构的健康检查；凡不属于法定健康检查对象范围内，可以不接受健康检查。如本人自愿要求健康检查，可由本人填写申请表接受检验检疫机构的健康检查服务。

根据《中华人民共和国国境卫生检疫法》及其实施细则、《外国人入境出境管理法实施细则》以及卫生部、公安部《关于中国公民出入境提交健康证明的通知》和《关于来华外国人提供健康证明问题的若干规定》等规定，申请来华定居，或任职、就业、学习在华居留一年或一年以上的外国人属于法定健康检查对象；经批准出国劳务、留学、探亲、定居及其他出境一年以上的中国公民或在境外居住三个月以上回国的中国公民为法定的健康检查对象；国际通行交通工具上的中国籍员工以及在出入境口岸和出入境交通工具上从事食品和饮用水的从业人员为法定的健康检查对象。

NOTE

Please read the following paragraph carefully to make clear whether you are required to receive health examination according to relevant laws and rules. If you are not the health examination object prescribed by laws and rules, you can’t do it. But if you need examination voluntarily for travel, you should fill in the application form and then receive the health examination by the entry-exit inspection and quarantine organizations of P.R.C.

According to <The Frontier Health And Quarantine Law Of P.R.C.>, <Specific Rules For Enforcing The Frontier Health And Quarantine Law Of P.R.C.>,< Specific Rules For Enforcing Law Of The People’s Republic Of China On Control Of The Entry And Exit Of Aliens> and <Notice For Persons Of Chinese Nationality To Submit Health Certificates>, <Rules For Foreigners Entering China To Submit Health Certificates> issued by the Ministry of Health and the Ministry of Public Security of China, any foreigner applying to settle down, work or study in China for one or more than one year is required to receive health examination, any person of Chinese nationality approved to work in, study in ,visit or immigrate into or live in another country for more than three months is required to receive health examination, any crew member of Chinese nationality on the means of transport for international voyage or any food or drinking water handler at a frontier port or on any inbound or outbound means of transport is required to receive health examination.

出 入 境 人 员 健 康 检 查 申 请 表

HEALTH EXAMINATION APPLICATION FORM

                                                       编号           

姓/Surname                名/Given name

性别/Sex            出生日期（日/月/年）/Birth date

国籍/Nationality          证件号码/Passport or ID No.

出生地/Birth place        职业/Occupation

单位名称/Name of unit

通讯地址（中国）/Mailing address (China)

电话号码（中国）/Telephone number (China)

目的地(国家或地区)                           停留时间（月）

按入境或出境目的分类/Classification by purpose of entering or departure （以打 ”√”选择 /To be completed with ”√”）

o入境（Entry）                            o出境（Exit）

o定居人员/ Immigrant                       o公务人员/ Officer

o商务人员/ Businessman(or woman)         o留学人员/ Student

o交通员工/ Staff of means of transport        o涉外婚姻/Transnational Marriage

o旅游/ Traveler                            o从业人员（食品和饮用水）Food & 

o探亲者/ Visitor                              drinking water handler

o归国人员/ Chinese back to China           o劳务人员 / labor

o其他人员/Others

既往病史/Past history

 

本人申明:以上提供的资料真实准确。如有不实填报，本人愿意承担由此引起的一切后果及法律责任。

申请人签名                                申请日期