COVID-19 Crew Change Health Declaration
Vessel Name
Crew Member Name
Rank / Position
Nationality
Date of Birth
Date of Embarkation
Date of Disembarkation
1. COVID-19 Symptoms
Have you experienced any of the following symptoms in the past 14 days?
Fever
Cough
Sore Throat
Shortness of Breath
Loss of taste/smell
None of the above
2. Exposure History
Have you been in close contact with anyone diagnosed or suspected of having COVID-19 in the last 14 days?
No
Yes
If YES, provide details
3. Travel History
Countries visited in the last 14 days
4. Vaccination Status
Have you received COVID-19 vaccination?
Yes
No
If YES, provide vaccine name(s) and date(s) administered
5. Quarantine / Isolation
Have you undergone quarantine or isolation prior to crew change?
No
Yes
If YES, provide place and duration
6. Declaration
I hereby declare that the information provided above is true and correct to the best of my knowledge.
Crew Member Signature
Date