Offshore Vessel Crew Health Screening Form
Crew Information
Full Name
Date of Birth
Rank/Position
Vessel Name
Crew ID/Passport Number
Health Questionnaire
1. Do you have any of the following symptoms?
Fever
Cough
Shortness of breath
Sore throat
None
2. Have you been in close contact with anyone who has tested positive for a communicable disease within the past 14 days?
Yes
No
3. Do you have any chronic medical conditions?
4. Are you currently taking any medication?
5. Any recent surgeries or hospitalizations (past 6 months)?
Declaration
I declare that the information provided above is true and complete to the best of my knowledge.
Crew Signature
Date