Maritime Crew COVID-19 Status Declaration
Crew Member Information
Full Name
Position/Rank
Nationality
Passport Number
Vessel Information
Vessel Name
IMO Number
Port of Arrival
Arrival Date
COVID-19 Health Status
Have you experienced any of the following symptoms in the past 14 days? (fever, cough, difficulty breathing, loss of taste/smell, etc.)
No
Yes
Have you been in close contact with a confirmed COVID-19 case in the last 14 days?
No
Yes
Most recent COVID-19 test date
COVID-19 test result
Negative
Positive
Declaration
I hereby declare that the information provided above is true and accurate to the best of my knowledge.
Crew Member Signature
Date