Maritime Chronic Illness Disclosure Form
Personal Information
Full Name
Date of Birth
Rank/Position
Employee/ID Number
Vessel/Ship Name
Chronic Illness Information
Name of Chronic Illness/Condition
Date Diagnosed
Medications/Treatments
Attending Physician/Specialist
Work Limitations/Restrictions
Additional Information
Describe Symptoms While Onboard
Emergency Procedures/Instructions
Declaration
I confirm the information provided is accurate to the best of my knowledge.
Signature
Date