Inland Waterways Crew Medical Declaration
Crew Member Details
Name:
Date of Birth:
Nationality:
Position:
Vessel Name:
Medical Declaration
1. Do you currently suffer from, or have you ever suffered from, any chronic illness, injury, or disability?
2. Are you currently under medical treatment or taking any prescribed medication?
3. Have you been hospitalised or undergone surgery during the past 5 years?
4. Do you have any allergies (including drug allergies)?
5. Do you have any condition which may affect your work on board?
Additional comments:
I hereby declare that the above information is true and correct to the best of my knowledge.
Signature of Crew Member
Date