1、旅 客 运 输 申 明 书Passenger Transportation Declaration本人 ，所持证件名称及号 码为 ，机票号 码为 。我于 年 月 日乘坐海南航空公司 航班由 出发（经停 ）前往 ，座位号 。I , possess passports / ID card numbers held are ,Ticket number is , I take flight of Hainan Airlines on Date Month Year from to , Seat No. is 本人特此声明 I especially to declare：1海南航空公司及其代理人己提醒
2、我注意，为了保证安全，遵守始发地、 经停地、目的地所在国家的法律及其他有关规定，必 须确保以下情况符合要求 Hainan Airlines and the agent have already called my attention ,in order to guarantee safe , observe the laws of departure station, stopover , country where one stays of destination and other relevant regulations, must insure the following requir
3、ements：(1) 旅行及有关证件 Travel and relevant certificates： 不能没有前往国的有效证件。 the effective certificate of the destination country. 不能没有有效的回程或者续程机票。the effective backward or continue ticket. 不能没有过境国家所需的所有文件。all required files of the transit country. 旅行证件不能 过期或者不符合旅行要求。travel document within period of validity
4、and accord with the traveling requirement . 不能没有携带本次旅行所需的足够资金。 carry enough fund for traveling. 转机时间不能不符合最短转机时间 的要求。time of making a connection have to accord with the demands for shortest time of making a connection .(2) 旅客自身的健康状况 Passengers own health status： 怀孕期在 36 周以内超 过 32 周的孕妇乘机，必须出示县、市级或者相当于
5、这一级（如国家二甲级）以上医院开具的可乘机证明。More than 32 weeks pregnant woman takes a plane within 36 weeks in period of pregnancy , must show county , it is or equivalent to first grade this (such as country two first rate ) whom the above hospital open can be seized the opportunity to prove to be at city level. 患病或者由
6、于自身健康状况不稳定，必须出示县、市级或者相当于这一级（如国家二甲级）以上医院开具的可乘机证明。Ill or because ones own health status is unstable, must show county , it is or equivalent to first grade this (such as country two first rate ) whom the above hospital open can be seized the opportunity to prove to be at city level. 其他情况 Others (3) 并且告
7、知，在旅行开始之前，上述非正 规情况必须加以纠正。And tell , before beginning in travel , informal situation described above must be corrected .2我在考虑所有后果之后，仍然决定按预定计划乘坐上述航班旅行。I still decide to take flight according to the scheduled plan after considering all consequences .3海南航空公司及其代理人对我己尽到全部提醒的 义务，我的此次旅行在自身的健康状况、旅行证件或者其他必备文件
8、方面若发生问题，与海南航空公司及其代理人无关。我同意承担一切后果，并保证不因此而向海南航空公司及其代理人提出法律诉讼和任何赔偿，并且愿意赔偿航空公司因本人持有非正规旅客证件旅行或者其它上述情况而遭受的一切损失。Hainan Airlines and their agent own to do all obligations to remind to me, if the problem takes place in ones own health status , travel document or other indispensable files in my travel once he
9、re, have nothing to do with airline and agent of Hainan. I agree to bear all consequences , guarantee not to put forward the legal lawsuit and any compensation to airline and agent of Hainan because of this , and would like to compensate for all losses that the airline suffers because of holding the
10、 informal passengers certificate travelling or other situations described above in person.在见证下，本人于 年 月 日签署此文件。Get off witness it is here, I sign this file on Date Month Year .旅客联系地址及联系方式 Passengers and Contact： 旅客或其监护人签名 Signature of Passenger /Guardian： 地面服务经办人签名 Signature of Ground Service Handler
11、： 航空公司代表签名 Signature of HNA Representative： 说明：1用途：用于特殊旅客自身状况不稳定或者自身原因乘机条件不充分，旅客认识 到存在的风险，坚持成行下填写；或者需要旅客证实其旅行及有关证件或者其他情况符合始发地、经停地、目的地所在国家的法律及其他有关规定时填写。Purpose: This form should be filled by the special passenger who apply the special care, whose healthiness condition is not steady or fall short of t
12、ransport qualification. Or the passenger should approve whose certificate is2填写人和填写要求：由旅客或其监护人填写，航空公司代表（海航基地地面服 务值 班人员，或者海航驻场代表，或者机长）及地面服务经办人员（值机人员，或者特殊旅客服务人员，或者登机口控制人 员）签字确 认。内容要详细、完整、属实，不能有漏项，字迹工整、页面清洁，不能随意涂改。Filling requirement: Filled in by the passenger or his guardian, cosigned for confirmatio
13、n with the representative of airline company (Ground Service Watch of HNA Base, Resident Representative of HNA Base, or Captain) and Ground Service Handler( check-in staff ,special passenger service staff. or boarding gate control )witness. Detailed, intact, true and without skip for contents to fil
14、l, writing carefully and neatly, keep page cleaned and not altered at will.3保管要求：由签字人 员所在部门专人负责 保管，定点存放，保存期 1 年。 Keep requirement : Kept by special messenger, preserved by fixed position, one year of shelf life .4本申明书一式三联 ，第一 联为航空公司代表 联；第二联为始发站地面服务联；第三 联为旅客联。This form is in triplicate: the first she
15、et is for airlines representative; the second sheet is for ground service department of airport of departure; the third sheet is for passenger.13-6b 附表 旅客运输申明书（背面）参考资料下述内容仅供航空旅行时参考：一、机上条件：1飞机具有密封，增 压客舱的特点。 舱内气压相当于 2300 公尺（7000 英尺）高度的大气压力，能引起体腔内气体的膨胀，同 时也造成轻度的缺氧状态。2飞机在飞行中会有轻微的 颠簸及震动。3机上服务人员只受过一般的急救训练
16、，也不可能更多地照看病人。4机舱内的活动范围和舒适程度受到机舱技术设备的一定限制。二、具有下列状况的人，一般不适于航空旅行，需要提供医疗检查：1心脏类病患者。处于极严重或者危急状态的心脏病患者，如严重的心力衰竭、呼吸急促、需深度吸氧、面有紫绀症状、健康状况有可能危及自身或者影响其他旅客安全的，或者心肌梗塞（在旅行前六周之内增发生过梗塞）者。2血色素量在 50%（Hb8g.dl）以下的贫血人员。3严重的中耳炎，伴随有耳咽管堵塞症的患者。4近两周内患自发性气胸的病人或者做过气脑 造影的神经系统病症的患者。5大纵隔瘤，特大疝 肿及肠梗阴的病人。6头部损伤， 颅内压增高及颅骨骨折者；下颌骨骨折最近使用
17、金属线连接者。7近期进行过外科手术，伤口未完全愈合者和产妇产后不满二周者。8在过去 30 天内患过脊髓灰质炎的病人；延髓型脊髓灰 质炎患者。9出生不满 14 天的婴儿。10孕妇。怀孕期在 36 周以内超过 32 周的孕妇乘机，需具有医生在 72 小时之内签署的诊断证明书。11年事较高旅客。一般老年人下肢静脉血液回流不好，高空 飞行会给老年人带来一定的不适并有可能带来身体损害。12其他不适于航空旅行的患病旅客。如冠心病、高血压、糖尿病、心脑血管病、哮喘等患者。三、海航拒绝运输的旅客：1下列传染病或者疑难病患者：霍乱、伤寒、副伤寒、 发疹性斑疹伤寒、痢疾、天花、猩 红热、白喉、鼠疫、流行性脑炎、脑
18、膜炎、开放期的肺结核及其他传染病。2精神病患者，易于 发发 狂，可能对其他旅客或者自身造成危害者。3健康情况可能危及自身或者影响其他旅客安全者。4旅客不遵守公共民用航空运输的规则，或者不听从承运人的安排和 劝导。四、必须提供诊断证明书的病患（伤）旅客：1担架旅客；2需要提供飞机上医疗氧气的病患旅客；3肢体病伤旅客；4承运人及其代理人怀疑在飞机上需要额外医疗服务的情况下，才能 够完成所需航程运输的旅客；5 怀孕期超 过 32 周在 36 周以内的孕 妇。五、以下人员必须在航班离站 48 小时以前提出乘机要求，得到海航明确给予承运的答复，并于其航班开始办理乘机手续 1 小时前来到海航或海航代理人柜
19、台办理乘机手续：1担架旅客；2病患 轮椅旅客；3携 带电池驱动轮椅的旅客；4旅客携 带的轮椅或者其他辅助设备的电池为危险品材料，需要海航妥善包装； 5残疾旅客团队超过（含）10 人以上；6需要机上医 疗氧气瓶的旅客； 7携 带保育箱旅客。注： 如果旅客没有提前告知海航或没有在 规 定的 时间 内来到 值 机柜台 办 理乘机手 续 ，海航尽力安排病残旅客所要求的服 务 或 设备 ，但是以不能延 误 航班为 前提。六：以下病残旅客必须由旅客提供陪护人员：1无自理能力轮椅旅客；2担架旅客；3心理疾病并且对发出的安全指令不能理解或者做出必要反应；4严重受伤（或损伤）造成行动不便，不能 够自己单独完成紧
20、急撤离；5听力或者 视力严重损伤旅客。注 ：陪 护 人 员 必 须 是成人且有自主能力，可 协 助病残旅客如 厕 、紧 急撤离及登机、下机，必 须 全程陪同， 须 熟悉病患病情并提供相关帮助，不可有其他任 务（如照 顾 儿童），能 够胜 任 处 理病患旅客机上医 疗 需要。七、其他：1患有疾病的旅客，如果乘机过程隐瞒病情所造成的后果，海航不承担责任。2未按上述要求办理运输手续的，海航不承担相关责任。ReferencesThe following contents are only for reference in air travel:I. Conditions on board 1. The
21、 airplanes cabin is sealed and pressurized. Cabin pressure is equivalent to the atmospheric conditions at 2300 meter (7000 ft), which cause expansion of body cavities and mild anaerobic conditions. 2. Great jolt and vibration may be occurred while flying. 3. The crew are only trained for common firs
22、t aid, and not allowed for patient injection. And, the crew should be in charge of the whole service during flight, having no time to attend the patients.4. The space of the cabin and comfortableness of activities are limited due to the technical equipment. II. Those with the following conditions ar
23、e generally not suitable for air travel. They should have medical examination before boarding:1. The patient suffering from cardiopathy. The cardiopath is of severe case or in critical status, e.g. severe heart failure, tachypnea, requiring deeply inhaling oxygen, with facial cyanosis, and the healt
24、h conditions may endanger himself or influence others, or myocardial infarction (The case of myocardial infarction occurred within six weeks before traveling).2. The person suffering from anemia with hematochrome level below 50% (Hb 8.0 g.dL)3. The patient suffering from severe tympanitis with obstr
25、uction of eustachian tubes. 4.The patient suffering from spontaneous pneumothorax within past two weeks or received pneumoencephalography (PEG) of the nervous system. 5. The patient suffering from mediastinum tumour, serious hernia and intestinal obstruction.6. The patient suffering from head injury
26、, intracranial hypertension and fracture of skull; and fracture of mandible joined with wire recently.7. The patient who have received a surgery operation recently, but the wound hasnt been healed up completely; and it is not exceeding two weeks after delivery for the parturient.8. The patient has s
27、uffered from poliomyelitic or bulbar poliomyelitis within past 30 days.9. The infant under 14-day age10. Pregnant woman. The pregnant woman whose pregnancy exceeding 32 weeks. (If the pregnant woman, whose pregnancy is more than 32 weeks but not exceeding 36 weeks, wants to take airplane, it require
28、s her to offer a physicians signed certificate of diagnosis dated within 72-hour before departure.) 11. The old passenger. Generally speaking, the high altitude flight may be uncomfortable to the old passengers and even cause harm to them, because of poor venous blood circulation of the lower limbs.
29、12. The other patients who are not suitable for air travel, such as the patients suffering from coronary heart disease, hypertension, diabetes, cardiovascular disease, cerebrovascular disease and asthma.III. HNA refuses to transport the following passengers:1. Those suffering from the following infe
30、ctious diseases or complicated diseases cholera, typhoid fever, paratyphoid fever, typhus, dysentery, smallpox, scarlatina, diphtheria, plague, epidemic encephalitis, meningitis, open tuberculosis and other infectious diseases. 2. The psychotic, easy out of mind that may cause danger to other passen
31、gers or itself.3. The health conditions may endanger himself or influence the safety of others.4. Those passengers who dont abide by the rules of public civil air transportation, or dont obey the carriers arrangement and advice. IV. The sick (wounded) passengers must provide “Certificate of Diagnosi
32、s“:1.The stretcher passenger; 2.The sick passenger may require extra therapeutic oxygen during flight; 3. The passenger with sick or wounded limbs; 4. For those passengers are doubted that they can take the flight only under the conditions of medical service by carrier and its agent; 5. The pregnant
33、 woman whose pregnancy exceeds 32 weeks but less than 36 weeks V. The following personnel are required to submit application for emplaning at least 48 hours before departure. After receiving the approval from HNA, they must check-in at the counter of HNA or the Agent of HNA one hour prior to the sch
34、eduled departure time. 1. The stretcher passenger; 2. Wheelchair sick passenger; 3. Passenger carrying battery-powered wheelchair; 4. The batteries of wheelchair or other auxiliary equipment are dangerous materials, which need to be well wrapped by HNA; 5. The number of a disabled passengers group e
35、xceeds (includes) 10 people; 6. Those passengers may require therapeutic bottled oxygen during flight; 7.The passenger carrying incubators. Note: If passenger doesnt give an advance notice to HNA or cant check-in within the scheduled time, HNA will try its best to arrange the related service or equi
36、pment required by sick and disable passengers, but subject to no delay of the flight.VI. The following sick or disable passengers must provide accompanied personnel. 1. Wheelchair passenger without self-servicing ability； 2. Stretcher passenger; 3. The passenger suffering from mental illness, or can
37、t understand or give a necessary response to the security instruction; 4.the passenger, who was incapacitated resulting from serious wound (or injury), can not evacuate by himself; 5.The passenger who has serious injury with poor audition or vision.Note: Attendant must be the adult, who has capacity
38、 for action and can assist the sick or disabled passenger to go to toilet, in urgent evacuation and enplaning and deplaning. The attendant must be familiar with illness and conditions of patient, accompanying the patient in the whole journey, also can offer other related assistance, but should not u
39、ndertake other duties (e.g. looking after the child), and can handle the medical conditions of patient during flight. VII. Others 1. HNA shall not bear any responsibilities arising from the passenger who conceal his patients conditions. 2. HNA shall not bear any relevant responsibilities for those who breach the above transportation procedure.注： 13-6 附表 应 以中英文 结 合印刷并交付 现场 使用，建 议 采用 ISO 标 准 A4 型 纸 （尺寸： 210297mm）。Note: 13-6 attached list should be printed in Chinese and English for use on site. It is proposed to adopt ISO standard Model A4 paper (size: 210297mm)
