Seafarer Quarantine Compliance Declaration

Personal Details

Full Name Rank/Position Vessel Name IMO Number Date of Arrival

Quarantine Information

Designated Quarantine Facility/Location Quarantine Period From Quarantine Period To Authority Overseeing Quarantine

Health Declaration

I declare that I have not experienced or exhibited symptoms of COVID-19 (such as fever, cough, sore throat, shortness of breath, loss of taste/smell) during my quarantine period.

I declare that I have not had close contact with any person suspected or confirmed to have COVID-19 during my quarantine period.

Other relevant information:

Declaration & Acknowledgment

I hereby declare that the above information is true and correct to the best of my knowledge and that I have complied with all quarantine and health protocols as required.

Signature of Seafarer

Date:

Authorized Person / Official

Date: