Keep ME Healthy Form for Maine Visitors

To help “Keep Maine Healthy,” guests of Maine commercial lodging establishments, campgrounds, seasonal rentals, or short-term rentals are required to complete this certificate prior to their stay. This initiative promotes the safety of Maine residents and visitors coming to enjoy all Maine has to offer. Guests under the age of 18, or residents of Maine, New Hampshire, Vermont, Connecticut, New Jersey or New York do not need to fill out the Certificate of Compliance. Please note that our hotel management or staff will not ask for any proof of compliance of the 14-day quarantine requirement, nor are we able to ask for proof of a negative COVID-19 test, due to HIPAA laws.

Keep Maine Healthy Certificate of Compliance for Maine Visitors

The State of Maine asks you to review and attest to the following:
1. I certify that I have not experienced or displayed any of the following COVID-19 symptoms in the last 24 hours:*
Select All
Fever or chills
Sore throat, cough, shortness of breath, or other respiratory symptoms
Muscle aches, severe fatigue, or chills
Changes in taste or smell
2. I certify that I have not had close contact with anyone over the last 14 days who is confirmed to have COVID-19.
3. I certify that ONE of the following is true (PLEASE CHECK ONE):*
I have received a negative test result for COVID-19 on a specimen taken no longer than 72 hours prior to my arrival, consistent with Maine CDC guidance; OR
I will quarantine for 14 days upon arrival in Maine or for the duration of the stay; OR
I have completed a 14-day quarantine in Maine prior to my stay.
(Note: Visitors may be tested for COVID-19 in Maine, but remain in quarantine while awaiting the result.)
4. While in Maine, I agree to do my part to Keep Maine Healthy by following recommended safety measures in order to protect myself and others.
5. I also certify that all persons in my care who are under the age of 18, or who are dependent on my care, meet the criteria described in items 1 and 2. Please provide the names and ages of such persons in your care.

First & Last Name Age
First & Last Name Age
6. I have read and understand this entire Certificate of Compliance and agree the certifications made above are accurate. Visitors may be asked to furnish proof of the negative test result upon request.*

Dated:
MM
DD
YYYY
Signature*
Printed Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Email*
Home Phone*
Phone while in Maine*