Port Entry Marine Crew Health Questionnaire
Vessel Information
Vessel Name
IMO Number
Port of Arrival
Date of Arrival
Last Port of Call
Flag
Crew Member Information
Name
Rank
Date of Birth
Passport / Seaman’s Book No.
Health Status
In the last 14 days, have you experienced any of the following symptoms? (Fever, cough, sore throat, shortness of breath, loss of taste/smell, etc.)
Have you been ill or felt unwell in the last 14 days?
Have you received any medical attention in the last 14 days?
Have you been in contact with any person(s) who is suspected or confirmed to have an infectious disease in the last 14 days?
Have you disembarked at any port in the last 14 days?
Additional Information
Other relevant medical or travel information
Declaration
Date
Crew Member Signature
Master/Ship Doctor Signature