Maritime COVID-19 Declaration Form
Vessel Name
IMO Number
Flag State
Call Sign
Captain/Master Name
Date of Arrival
Port of Origin
Last Port of Call
Total Number of Crew
Total Number of Passengers
Have any crew or passengers experienced any of the following symptoms in the past 14 days?
Fever
Cough
Respiratory distress
Loss of taste or smell
Sore throat
Has anyone onboard tested positive for COVID-19 in the last 14 days?
Yes
No
Actions taken (isolation, medical care, etc.):
Date of Declaration
Signature of Master/Captain