Ferry Boat Crew International Travel Health Declaration
Crew Member Information
Full Name
Date of Birth
Gender
Male
Female
Other
Passport Number
Nationality
Crew ID/Employee Number
Contact Information
Address
Phone Number
Email
Travel Information
Vessel Name
Port of Departure
Port of Arrival
Departure Date
Arrival Date
Health Information
Do you currently have any of the following symptoms? (Check all that apply)
Fever
Cough
Shortness of Breath
Body Aches
None
Have you been ill or had any medical treatment in the last 14 days?
Yes
No
If yes, please provide details
Have you been in contact with anyone diagnosed with an infectious disease (e.g., COVID-19) in the last 14 days?
Yes
No
Additional Information or Declarations
Please mention anything else relevant or any underlying health conditions
Signature
Date