Vessel Entry Health Assessment Form
Vessel Name
IMO Number
Port of Entry
Date of Entry
Master's Name
Total Number of Crew Onboard
Total Number of Passengers Onboard
Has any person onboard shown signs of illness?
Yes
No
If yes, provide details
Is there any person who joined or left the vessel in the last 14 days?
Yes
No
If yes, provide details
Has the vessel visited any ports in affected areas within the last 30 days?
Yes
No
If yes, list the ports and dates
Additional Information
Name of Person Completing Form
Position/Title
Date