Cargo Ship Crew Health Declaration Form
Vessel Name
IMO Number
Port of Arrival
Arrival Date
Captain's Name
Total Number of Crew Onboard
List of Crew Members
Name
Position/Rank
Nationality
Passport/ID Number
Health Status
Have any crew members displayed any of the following symptoms in the last 14 days? (Fever, cough, sore throat, difficulty breathing, fatigue, etc.)
No
Yes
If yes, provide details
Is there any ongoing illness or contagious disease on board?
No
Yes
If yes, provide details
Date
Signature of Captain / Authorized Officer