Vessel Entry COVID-19 Health Screening Form
Full Name
Vessel Name
Rank/Position
Date of Entry
Contact Number
1. Symptoms (in the last 14 days)
Fever
Cough
Sore Throat
Shortness of Breath
Loss of Smell or Taste
None
2. Exposure History
Have you had close contact with a confirmed or suspected COVID-19 case in the last 14 days?
Yes
No
Countries or ports visited in the last 14 days
Additional Comments
Signature
Date