International Crew Travel Health Declaration
Crew Member Information
Full Name
Employee ID
Passport Number
Nationality
Flight / Voyage Number
Position / Rank
Travel History (Last 14 days)
Countries/Regions Visited
Health Declaration
In the past 14 days, have you experienced any of the following symptoms? (Select all that apply)
Fever
Cough
Shortness of Breath
Sore Throat
None of the above
In the past 14 days, have you had close contact with a suspected or confirmed case of infectious disease?
Yes
No
Other Relevant Information
Date
Signature