Seafarer Pre-Boarding Health Declaration
Personal Information
Full Name
Rank/Position
Nationality
Vessel Name
Embarkation Date
Port of Embarkation
Travel History (Last 14 Days)
Countries/Ports Visited
Health Status
Have you experienced any of the following symptoms in the past 14 days?
Fever
Cough
Sore Throat
Difficulty Breathing
Headache
None
Have you had contact with a confirmed or suspected COVID-19 case in the last 14 days?
Yes
No
Are you currently taking any medication?
Yes
No
Declaration
I hereby declare that the information given above is true and correct to the best of my knowledge.
Signature
Date