vault backup: 2026-04-05 17:46:47

documents/travel/china_2021/flight_xmn_lax_jiang_59h.md

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+---
+type: flight-itinerary
+category: travel
+person: Xuewei Jiang
+date: 2022-02-09
+source: flight_xmn_lax_jiang_59h.pdf
+---
+
+# Flight Itinerary / E-Ticket — Jiang Xuewei (Electronic Ticket Receipt)
+
+## Page 1 (English)
+
+| Field | Value |
+|-------|-------|
+| Airline PNR | NFJ2TR |
+| Name | JIANG/XUEWEI |
+| ID Number | EJ4954380 |
+| Issuing Airline | MIS CAAC |
+| 1E PNR | NFJ2TR |
+| ETKT NBR | 731-2160069062 |
+| CONJ NBR | — |
+| Date of Issue | 24DEC21 |
+| IATA Code | 10048001 |
+
+### Flight Details
+
+| Field | Value |
+|-------|-------|
+| Origin | XMN — Gaoqi Intl Airport |
+| Destination | LAX — Los Angeles International Airport |
+| Flight | MF829 |
+| Class | K |
+| Date | 09FEB |
+| Departure Time | 23:30 |
+| Arrival Time | 20:00 |
+| Period | 09FEB22/09FEB22 |
+| Status | OK |
+| Baggage Allowance | 2PC |
+| Terminal (Takeoff) | T3 |
+| Terminal (Arrival) | B |
+
+### Fare Details
+
+| Field | Value |
+|-------|-------|
+| Fare Calculation | M 09FEB22XMN MF LAX781.42NUC781.42END ROE6.398550 XT 3.96XA7.00XY6.11YC4.00YQ157.00YR |
+| Form of Payment | MS MFPAEXT/14242400000019364874 |
+| Tax | USD,14.1,CN; USD,19.1,US; USD,3.96,XA |
+| Fare | CNY5000.0 |
+| Total | USD996.27 |
+| Restrictions | Q/NONEND/PENALTY APPLIES |
+
+## Page 2 (Chinese — 电子客票行程单)
+
+Same information as above rendered in Chinese:
+
+| 字段 | 内容 |
+|------|------|
+| 航空公司记录编号 | NFJ2TR |
+| 旅客姓名 | JIANG/XUEWEI |
+| 身份识别代码 | EJ4954380 |
+| 出票航空公司 | MIS CAAC |
+| 订座记录编号 | NFJ2TR |
+| 票号 | 731-2160069062 |
+| 出票时间 | 24DEC21 |
+| 航协代码 | 10048001 |
+| 始发地 | 厦门高崎 |
+| 目的地 | 洛杉矶国际机场 |
+| 航班 | MF829 |
+| 座位等级 | K |
+| 日期 | 09FEB |
+| 起飞时间 | 23:30 |
+| 到达时间 | 20:00 |
+| 有效期 | 09FEB22/09FEB22 |
+| 客票状态 | OK |
+| 行李 | 2PC |
+| 航站楼 (起飞) | T3 |
+| 航站楼 (到达) | B |
+| 票价计算 | M 09FEB22XMN MF LAX781.42NUC781.42END ROE6.398550 XT 3.96XA7.00XY6.11YC4.00YQ157.00YR |
+| 付款方式 | MS MFPAEXT/14242400000019364874 |
+| 税款 | USD,14.1,CN; USD,19.1,US; USD,3.96,XA |
+| 机票款 | CNY5000.0 |
+| 总额 | USD996.27 |
+| 限制条件 | Q/NONEND/PENALTY APPLIES |

documents/travel/china_2021/flight_xmn_lax_lu_59e.md

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+---
+type: flight-itinerary
+category: travel
+person: Yanxin Lu
+date: 2022-02-09
+source: flight_xmn_lax_lu_59e.pdf
+---
+
+# Flight Itinerary / E-Ticket — Lu Yanxin (Electronic Ticket Receipt)
+
+## Page 1 (English)
+
+| Field | Value |
+|-------|-------|
+| Airline PNR | NFJ2TR |
+| Name | LU/YANXIN |
+| ID Number | E93603635 |
+| Issuing Airline | MIS CAAC |
+| 1E PNR | NFJ2TR |
+| ETKT NBR | 731-2160069063 |
+| CONJ NBR | — |
+| Date of Issue | 24DEC21 |
+| IATA Code | 10048001 |
+
+### Flight Details
+
+| Field | Value |
+|-------|-------|
+| Origin | XMN — Gaoqi Intl Airport |
+| Destination | LAX — Los Angeles International Airport |
+| Flight | MF829 |
+| Class | K |
+| Date | 09FEB |
+| Departure Time | 23:30 |
+| Arrival Time | 20:00 |
+| Period | 09FEB22/09FEB22 |
+| Status | OK |
+| Baggage Allowance | 2PC |
+| Terminal (Takeoff) | T3 |
+| Terminal (Arrival) | B |
+
+### Fare Details
+
+| Field | Value |
+|-------|-------|
+| Fare Calculation | M 09FEB22XMN MF LAX781.42NUC781.42END ROE6.398550 XT 3.96XA7.00XY6.11YC4.00YQ157.00YR |
+| Form of Payment | MS MFPAEXT/14242400000019364874 |
+| Tax | USD,14.1,CN; USD,19.1,US; USD,3.96,XA |
+| Fare | CNY5000.0 |
+| Total | USD996.27 |
+| Restrictions | Q/NONEND/PENALTY APPLIES |
+
+## Page 2 (Chinese — 电子客票行程单)
+
+Same information as above rendered in Chinese:
+
+| 字段 | 内容 |
+|------|------|
+| 航空公司记录编号 | NFJ2TR |
+| 旅客姓名 | LU/YANXIN |
+| 身份识别代码 | E93603635 |
+| 出票航空公司 | MIS CAAC |
+| 订座记录编号 | NFJ2TR |
+| 票号 | 731-2160069063 |
+| 出票时间 | 24DEC21 |
+| 航协代码 | 10048001 |
+| 始发地 | 厦门高崎 |
+| 目的地 | 洛杉矶国际机场 |
+| 航班 | MF829 |
+| 座位等级 | K |
+| 日期 | 09FEB |
+| 起飞时间 | 23:30 |
+| 到达时间 | 20:00 |
+| 有效期 | 09FEB22/09FEB22 |
+| 客票状态 | OK |
+| 行李 | 2PC |
+| 航站楼 (起飞) | T3 |
+| 航站楼 (到达) | B |
+| 票价计算 | M 09FEB22XMN MF LAX781.42NUC781.42END ROE6.398550 XT 3.96XA7.00XY6.11YC4.00YQ157.00YR |
+| 付款方式 | MS MFPAEXT/14242400000019364874 |
+| 税款 | USD,14.1,CN; USD,19.1,US; USD,3.96,XA |
+| 机票款 | CNY5000.0 |
+| 总额 | USD996.27 |
+| 限制条件 | Q/NONEND/PENALTY APPLIES |

documents/travel/china_2021/jiang_vaccine_3rd_shot.md

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+---
+type: vaccine-record
+category: travel
+person: Xuewei Jiang
+date: 2021-11-24
+source: jiang_vaccine_3rd_shot.jpg
+---
+
+# COVID-19 Vaccination Record Card — Jiang Erica (Xuewei)
+
+> **Note:** This file is a duplicate of the same image archived in `medical/covid/jiang_vaccine_3rd_shot.jpg`. It is retained here because it was used as a supporting document for China travel in 2021-2022.
+
+| Field | Value |
+|-------|-------|
+| Last Name | Jiang |
+| First Name | Erica (Xuewei) |
+| MI | — |
+| Date of Birth | 03/13/1993 |
+| Patient Number | — |
+
+## Vaccination Records
+
+| Dose | Vaccine | Product Name/Manufacturer | Lot Number | Date | Healthcare Professional or Clinic Site |
+|------|---------|--------------------------|------------|------|---------------------------------------|
+| 1st Dose COVID-19 | Pfizer | Pfizer | ER8729 | 4/6/21 | LAFD USC |
+| 2nd Dose COVID-19 | Pfizer | Pfizer | EW 0171 | 4/27/21 | LAFD - USC |
+| Other | Pfizer | Pfizer | FJ1620 | 11/24/21 | USC Pharmacy |
+| Other | — | — | — | — | — |
+
+Scanned by TapScanner.

documents/travel/china_2021/lu_vaccine_2nd_shot.md

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+---
+type: vaccine-record
+category: travel
+person: Yanxin Lu
+date: 2021-05-06
+source: lu_vaccine_2nd_shot.jpg
+---
+
+# COVID-19 Vaccination Record Card — Lu Yanxin
+
+> **Note:** This file is a duplicate of the same image archived in `medical/covid/lu_vaccine_2nd_shot.jpg`. It is retained here because it was used as a supporting document for China travel in 2021-2022.
+
+Two cards are shown in this image (original and replacement/updated).
+
+## Card 1 (Top)
+
+| Field | Value |
+|-------|-------|
+| Last Name | Lu |
+| First Name | Yanxin |
+| MI | — |
+| Date of Birth | 10/17/1989 |
+| Patient Number | — |
+
+| Dose | Vaccine | Lot # | EXP | Date | Healthcare Professional or Clinic Site |
+|------|---------|-------|-----|------|---------------------------------------|
+| 1st Dose COVID-19 | PFIZER COVID-19 VACCINE | EW0161 | 07/31/2021 | 4/15/2021 | FORUM |
+| 2nd Dose COVID-19 | — | — | — | — | — |
+| Other | — | — | — | — | — |
+| Other | — | — | — | — | — |
+
+## Card 2 (Bottom)
+
+| Field | Value |
+|-------|-------|
+| Last Name | Lu |
+| First Name | Yanxin |
+| MI | — |
+| Date of Birth | 10-17-1989 |
+| Patient Number | — |
+
+| Dose | Vaccine | Product Name/Manufacturer | Lot Number | Date | Healthcare Professional or Clinic Site |
+|------|---------|--------------------------|------------|------|---------------------------------------|
+| 1st Dose COVID-19 | Pfizer | Pfizer | EW0161 | 4/15/21 | Forum |
+| 2nd Dose COVID-19 | PFIZER COVID-19 VACCINE | — | EW0173 | 5/6/2021 (EXP: 08/31/2021) | FORUM |
+| Other | — | — | — | — | — |
+
+Scanned by TapScanner.

documents/travel/china_2021/lu_vaccine_record_2022.md

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+---
+type: vaccine-record
+category: travel
+person: Yanxin Lu
+date: 2022-02-24
+source: lu_vaccine_record_2022.jpg
+---
+
+# SMART Health Card — Lu Yanxin (California Digital COVID-19 Vaccine Record)
+
+Screenshot from CA.GOV State of California digital vaccine record system.
+
+| Field | Value |
+|-------|-------|
+| Name | Yanxin Lu |
+| DOB | 10/17/1989 |
+
+## Vaccination Records
+
+| Dose | Dose Date | Dose Type/Manufacturer |
+|------|-----------|----------------------|
+| 1 | 04/15/2021 | Pfizer |
+| 2 | 05/06/2021 | Pfizer |
+| 3 (Booster) | 02/24/2022 | Pfizer |
+
+The image includes a SMART Health Card QR code for digital verification.

documents/travel/china_2021/test_result_jiang.md

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+---
+type: test-result
+category: travel
+person: Xuewei Jiang
+date: 2021-12-17
+source: test_result_jiang.pdf
+---
+
+# COVID-19 Test Result — Jiang Xuewei
+
+## Lab Information
+
+| Field | Value |
+|-------|-------|
+| Lab | Genentox Labs / Nova Diagnostics Labs |
+| Address | 2001 E 1st St Ste 109, Santa Ana, CA 92705 |
+| Phone | 833-668-2522 |
+| CLIA# | 05D0871568 |
+| Lab Director | Rosaura Williams MD |
+| Email | results@novadxlabs.com |
+| Report Type | Final Report — SARS RT-PCR FLY |
+
+## Patient Information
+
+| Field | Value |
+|-------|-------|
+| Name | Jiang, Xuewei |
+| DOB | 03/13/1993 |
+| Gender | Female |
+| Address | 11950 Idaho Ave. Apt. 113, Los Angeles, CA 90025 |
+| MRN | EJ4954380 |
+
+## Sample Information
+
+| Field | Value |
+|-------|-------|
+| Collected | 12/17/2021 11:02 |
+| Received | 12/17/2021 |
+| Reported | 12/17/2021 |
+
+## Clinic Information
+
+| Field | Value |
+|-------|-------|
+| Client | Chinese Consulate |
+| Site | LAX Walk In |
+| Physician | Maxwell Y Jen |
+
+## Detailed Results Summary
+
+| Specimen ID | Test | Specimen Type | Results | Expected Value |
+|-------------|------|---------------|---------|----------------|
+| 391192 | SARS CoV-2 (Covid-19) by RT-PCR (NAAT) | Nasopharyngeal Swab | Not Detected (negative) | Not Detected |
+| 391193 | COVID-19 IgM (Chemiluminescence) | Venous Blood Draw | Detected (1.11 s/co) | <1 |
+| 391194 | N-Protein | Blood Drop | Not Detected | Not Detected |
+
+**Resulted By:** Eyas Mousa
+**Date:** 12/17/2021
+
+**Final Result for SARS CoV-2 (COVID-19): NOT DETECTED (negative)**
+
+> Note: IgM was Detected (1.11 s/co) which is above the expected value of <1, but the overall final result was still NOT DETECTED (negative) based on the RT-PCR (NAAT) test.
+
+## Disclaimers
+
+Not Detected (negative) results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information. Collection of multiple specimens or types of specimens may be necessary to detect virus. Improper specimen collection and handling, sequence variability under primers/probes or viruses present below the limit of detection may lead to false negative results. Positive and negative predictive values of testing are highly dependent on prevalence. False negative test results are more likely when prevalence is high.
+
+This test has been authorized by the FDA under an Emergency Use Authorization (EUA). The test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostic tests for detection and/or diagnosis of SARS-CoV-2 under Section 564(b)(1) of the Act, 21 U.S.C. section 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner. FDA review of the validation is pending.
+
+The SARS-CoV-2 test is intended for the qualitative detection of nucleic acids from SARS-CoV-2 in nasal, nasopharyngeal and oropharyngeal swab samples from patients who meet COVID-19 clinical and/or epidemiological criteria. Testing methodology is (Real Time) RT-PCR. The assay targets the S, N and ORF1ab genes. Test results must be correlated with clinical presentation and evaluated in the context of another laboratory and epidemiologic data. Test performance can be affected because the epidemiology and clinical spectrum of infection caused by SARS-CoV-2 is not fully understood.
+
+Genentox Laboratories, LLC. DBA Nova Diagnostics Labs CLIA Certification Number: 05D0871568 is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. section 263a, to perform high complexity tests.

documents/travel/china_2021/test_result_lu.md

@@ -0,0 +1,70 @@
+---
+type: test-result
+category: travel
+person: Yanxin Lu
+date: 2021-12-17
+source: test_result_lu.pdf
+---
+
+# COVID-19 Test Result — Lu Yanxin
+
+## Lab Information
+
+| Field | Value |
+|-------|-------|
+| Lab | Genentox Labs / Nova Diagnostics Labs |
+| Address | 2001 E 1st St Ste 109, Santa Ana, CA 92705 |
+| Phone | 833-668-2522 |
+| CLIA# | 05D0871568 |
+| Lab Director | Rosaura Williams MD |
+| Email | results@novadxlabs.com |
+| Report Type | Final Report — SARS RT-PCR FLY |
+
+## Patient Information
+
+| Field | Value |
+|-------|-------|
+| Name | Lu, Yanxin |
+| DOB | 10/17/1989 |
+| Gender | Male |
+| Address | 11950 Idaho Ave. Apt. 113, Los Angeles, CA 90025 |
+| MRN | E93603635 |
+
+## Sample Information
+
+| Field | Value |
+|-------|-------|
+| Collected | 12/17/2021 11:53 |
+| Received | 12/17/2021 |
+| Reported | 12/17/2021 |
+
+## Clinic Information
+
+| Field | Value |
+|-------|-------|
+| Client | Chinese Consulate |
+| Site | LAX Walk In |
+| Physician | Maxwell Y Jen |
+
+## Detailed Results Summary
+
+| Specimen ID | Test | Specimen Type | Results | Expected Value |
+|-------------|------|---------------|---------|----------------|
+| 391449 | SARS CoV-2 (Covid-19) by RT-PCR (NAAT) | Nasopharyngeal Swab | Not Detected (negative) | Not Detected |
+| 391450 | COVID-19 IgM (Chemiluminescence) | Venous Blood Draw | Not Detected (negative) (0 s/co) | <1 |
+| 391451 | N-Protein | Blood Drop | Not Detected | Not Detected |
+
+**Resulted By:** Eyas Mousa
+**Date:** 12/17/2021
+
+**Final Result for SARS CoV-2 (COVID-19): NOT DETECTED (negative)**
+
+## Disclaimers
+
+Not Detected (negative) results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions. Negative results must be combined with clinical observations, patient history, and epidemiological information. Collection of multiple specimens or types of specimens may be necessary to detect virus. Improper specimen collection and handling, sequence variability under primers/probes or viruses present below the limit of detection may lead to false negative results. Positive and negative predictive values of testing are highly dependent on prevalence. False negative test results are more likely when prevalence is high.
+
+This test has been authorized by the FDA under an Emergency Use Authorization (EUA). The test is only authorized for the duration of the declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostic tests for detection and/or diagnosis of SARS-CoV-2 under Section 564(b)(1) of the Act, 21 U.S.C. section 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner. FDA review of the validation is pending.
+
+The SARS-CoV-2 test is intended for the qualitative detection of nucleic acids from SARS-CoV-2 in nasal, nasopharyngeal and oropharyngeal swab samples from patients who meet COVID-19 clinical and/or epidemiological criteria. Testing methodology is (Real Time) RT-PCR. The assay targets the S, N and ORF1ab genes. Test results must be correlated with clinical presentation and evaluated in the context of another laboratory and epidemiologic data. Test performance can be affected because the epidemiology and clinical spectrum of infection caused by SARS-CoV-2 is not fully understood.
+
+Genentox Laboratories, LLC. DBA Nova Diagnostics Labs CLIA Certification Number: 05D0871568 is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), 42 U.S.C. section 263a, to perform high complexity tests.

documents/travel/china_2021/新冠疫苗接种声明书_jiang.md

@@ -0,0 +1,37 @@
+---
+type: vaccine-declaration
+category: travel
+person: Xuewei Jiang
+date: 2021-12-16
+source: 新冠疫苗接种声明书_jiang.jpg
+---
+
+# 新冠疫苗接种声明书 / Letter of Commitment on COVID-19 Vaccination — Jiang Xuewei (Signed Copy)
+
+This is a scanned/photographed copy of the signed declaration form. The PDF version (疫苗接种声明书_jiang.pdf) contains the same content. This JPG shows the completed form with handwritten signature.
+
+## Declarant Information
+
+| Field | Value |
+|-------|-------|
+| Name (声明人姓名) | 姜薛伟 |
+| Gender (性别) | 女 (Female) |
+| Date of Birth (出生日期) | 1993年3月13日 |
+| Passport No. (护照号) | EJ4954380 |
+| Telephone (电话) | +12542149350 |
+| Email (电邮) | xueweijiang0313@gmail.com |
+
+## Vaccination Details
+
+| Field | Value |
+|-------|-------|
+| Vaccine brand name (疫苗品牌名称) | 辉瑞 (Pfizer) |
+| Vaccination institution (接种机构名称) | University of Southern California |
+| Address (接种机构地址) | 3701 Flower St, Los Angeles, CA 90007 |
+| Contact (接种机构联系方式) | 213-740-9355 |
+| Doses (剂次) | Two doses (二剂次) checked |
+| First dose date (第一剂接种日期) | 2021年4月6日 |
+| Second dose date (第二剂接种日期) | 2021年4月27日 |
+
+**Signature:** (handwritten signature present)
+**Date:** 2021年12月16日

documents/travel/china_2021/新冠疫苗接种声明书_lu.md

@@ -0,0 +1,37 @@
+---
+type: vaccine-declaration
+category: travel
+person: Yanxin Lu
+date: 2021-12-16
+source: 新冠疫苗接种声明书_lu.jpg
+---
+
+# 新冠疫苗接种声明书 / Letter of Commitment on COVID-19 Vaccination — Lu Yanxin (Signed Copy)
+
+This is a scanned/photographed copy of the signed declaration form. The PDF version (疫苗接种声明书_lu.pdf) contains the same content. This JPG shows the completed form with handwritten signature.
+
+## Declarant Information
+
+| Field | Value |
+|-------|-------|
+| Name (声明人姓名) | 陆彦忻 |
+| Gender (性别) | 男 (Male) |
+| Date of Birth (出生日期) | 1989年10月17日 |
+| Passport No. (护照号) | E93603635 |
+| Telephone (电话) | +12542241457 |
+| Email (电邮) | crac1017@gmail.com |
+
+## Vaccination Details
+
+| Field | Value |
+|-------|-------|
+| Vaccine brand name (疫苗品牌名称) | 辉瑞 (Pfizer) |
+| Vaccination institution (接种机构名称) | Forum Stadium |
+| Address (接种机构地址) | 3900 W Manchester Blvd, Inglewood, CA, 90305 |
+| Contact (接种机构联系方式) | 833-540-0473 |
+| Doses (剂次) | Two doses (二剂次) checked |
+| First dose date (第一剂接种日期) | 2021年4月15日 |
+| Second dose date (第二剂接种日期) | 2021年5月6日 |
+
+**Signature:** (handwritten signature present)
+**Date:** 2021年12月16日

documents/travel/china_2021/疫苗接种声明书_jiang.md

@@ -0,0 +1,48 @@
+---
+type: vaccine-declaration
+category: travel
+person: Xuewei Jiang
+date: 2021-12-16
+source: 疫苗接种声明书_jiang.pdf
+---
+
+# 新冠疫苗接种声明书 / Letter of Commitment on COVID-19 Vaccination — Jiang Xuewei
+
+## Declarant Information
+
+| Field (中文) | Field (English) | Value |
+|------------|-----------------|-------|
+| 声明人姓名 | Name | 姜薛伟 |
+| 性别 | Gender | 女 (Female) |
+| 出生日期 | Date of Birth | 1993年3月13日 |
+| 护照号 | Passport No. | EJ4954380 |
+| 电话 | Telephone | +12542149350 |
+| 电邮 | Email | xueweijiang0313@gmail.com |
+
+## Statement (声明内容)
+
+1. 本人已接种新冠疫苗，接种详情如下 / I have received COVID-19 vaccination and the details are as follows:
+
+| # | Field (中文) | Field (English) | Value |
+|---|-----------|-----------------|-------|
+| 1 | 疫苗品牌名称 | Vaccine brand name | 辉瑞 (Pfizer) |
+| 2 | 接种机构名称 | Name of vaccination institution | University of Southern California |
+| 3 | 接种机构地址 | Address of vaccination institution | 3701 Flower St, Los Angeles, CA 90007 |
+| 4 | 接种机构联系方式 | Contact information | 213-740-9355 |
+| 5 | 疫苗接种剂次 | Doses | 二剂次 / Two doses (checked) |
+
+### Vaccination Dates
+
+| Dose | Date |
+|------|------|
+| 第一剂 / First dose | 2021年4月6日 |
+| 第二剂 / Second dose | 2021年4月27日 |
+
+2. 本人所附疫苗接种凭证（接种卡或其它接种证明）真实无误。
+I hereby declare that the attached vaccination certificate (vaccination card or other forms of certification) is true and accurate.
+
+本人保证以上所有内容真实，并愿意承担由此引起的一切法律责任，包括但不限于因虚报、瞒报导致被限制去中国旅行或被追究法律责任等后果。
+I hereby declare that the information provided above is true, and I shall bear all legal responsibilities arising therefrom, including but not limited to restricted travel to China, punishment by law, or other consequences in the case of partial or false disclosures.
+
+**声明人签名 / Signature:** (signed)
+**日期 / Date:** 2021年12月16日

documents/travel/china_2021/疫苗接种声明书_lu.md

@@ -0,0 +1,48 @@
+---
+type: vaccine-declaration
+category: travel
+person: Yanxin Lu
+date: 2021-12-16
+source: 疫苗接种声明书_lu.pdf
+---
+
+# 新冠疫苗接种声明书 / Letter of Commitment on COVID-19 Vaccination — Lu Yanxin
+
+## Declarant Information
+
+| Field (中文) | Field (English) | Value |
+|------------|-----------------|-------|
+| 声明人姓名 | Name | 陆彦忻 |
+| 性别 | Gender | 男 (Male) |
+| 出生日期 | Date of Birth | 1989年10月17日 |
+| 护照号 | Passport No. | E93603635 |
+| 电话 | Telephone | +12542241457 |
+| 电邮 | Email | crac1017@gmail.com |
+
+## Statement (声明内容)
+
+1. 本人已接种新冠疫苗，接种详情如下 / I have received COVID-19 vaccination and the details are as follows:
+
+| # | Field (中文) | Field (English) | Value |
+|---|-----------|-----------------|-------|
+| 1 | 疫苗品牌名称 | Vaccine brand name | 辉瑞 (Pfizer) |
+| 2 | 接种机构名称 | Name of vaccination institution | Forum Stadium |
+| 3 | 接种机构地址 | Address of vaccination institution | 3900 W Manchester Blvd, Inglewood, CA, 90305 |
+| 4 | 接种机构联系方式 | Contact information | 833-540-0473 |
+| 5 | 疫苗接种剂次 | Doses | 二剂次 / Two doses (checked) |
+
+### Vaccination Dates
+
+| Dose | Date |
+|------|------|
+| 第一剂 / First dose | 2021年4月15日 |
+| 第二剂 / Second dose | 2021年5月6日 |
+
+2. 本人所附疫苗接种凭证（接种卡或其它接种证明）真实无误。
+I hereby declare that the attached vaccination certificate (vaccination card or other forms of certification) is true and accurate.
+
+本人保证以上所有内容真实，并愿意承担由此引起的一切法律责任，包括但不限于因虚报、瞒报导致被限制去中国旅行或被追究法律责任等后果。
+I hereby declare that the information provided above is true, and I shall bear all legal responsibilities arising therefrom, including but not limited to restricted travel to China, punishment by law, or other consequences in the case of partial or false disclosures.
+
+**声明人签名 / Signature:** (signed)
+**日期 / Date:** 2021年12月16日