Maritime Traveler Symptom Self-Declaration
Personal Information
Full Name
Date of Birth
Nationality
Passport/ID Number
Vessel Name / Voyage No.
Symptoms (past 14 days)
Fever
Cough
Shortness of Breath
Fatigue
Loss of Taste or Smell
Sore Throat
Headache
Muscle or Body Aches
Nausea or Vomiting
Diarrhea
Travel & Exposure History (past 14 days)
Countries or Ports Visited
Close contact with confirmed/suspected infectious disease cases?
Yes
No
Declaration
I certify that the information provided above is true and complete to the best of my knowledge.