Offshore Crew Pre-Boarding Health Declaration
Personal Information
Full Name
Crew ID / Staff Number
Position / Designation
Nationality
Date of Birth
Contact Number
Travel & Embarkation Details
Vessel/Platform Name
Embarkation Date
Port/Departure Location
Health Declaration
Have you experienced any of the following symptoms within the last 14 days? (Check all that apply)
Fever / Chills
Cough
Shortness of Breath
Sore Throat
None of the Above
Other symptoms (please specify):
Have you been in close contact with anyone diagnosed with a contagious disease in the last 14 days?
Yes
No
If yes, provide details:
Have you received all required vaccinations as per company guideline?
Yes
No
List types/dates of recent vaccinations:
Declaration & Signature
I hereby declare the above information is true to the best of my knowledge.
Date
Signature (type name)