MINISTRY OF HEALTH WELLNESS AND THE ENVIRONMENT
Passport: __________________________ Gender:___________________________________
Date of Arrival: _____________________ Nationality: ______________________________
1. You have been assessed as a possible risk for the transmission of the Novel Coronavirus known as COVID19. The Chief Medical Officer of Antigua and Barbuda, who is the Quarantine Authority, in accordance with
the powers vested by section 6 of the Quarantine Act, Cap.361 and Quarantine Order No. 17 of 2020, has
directed that you be quarantined in your home or a designated facility for observation for fourteen days.
2. You are not allowed to leave your home or the designated facility during this period. Failure to comply with
these quarantine directions you will be liable on conviction to a fine of ten thousand dollars ($10,000.00) or
imprisonment for six (6) months or to both.
3. During your quarantine period, you will be in contact daily with an officer of the Quarantine Authority.
4. If you develop a fever, cough, shortness of breath or difficulty breathing you may require hospitalization and
must immediately contact the officer of the Quarantine Authority assigned to you.
I have read, understood and I am willing to comply with the instructions stated above.
Name of Passenger Signature of Passenger
Name of Officer Signature of Officer
For and on behalf of the Quarantine Authority