Yacht Crew Contagious Disease Self-Declaration Form
Crew Member Information
Full Name
Passport Number
Nationality
Date of Birth
Role/Position
Yacht Name
Health Declaration
1. Have you experienced any of the following symptoms in the past 14 days? (Check all that apply)
Fever
Cough
Sore Throat
Shortness of Breath
Loss of Smell/Taste
None
2. Have you been diagnosed with a contagious disease in the past 14 days?
Yes
No
3. Have you been in contact with anyone who has been diagnosed with a contagious disease in the past 14 days?
Yes
No
4. If YES to questions 2 or 3, please provide details:
Declaration
I declare that the information provided above is true and correct to the best of my knowledge.
Signature:
Date: