Maritime Passenger Health Screening Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Nationality
Passport/ID Number
Voyage Number / Ship Name
Cabin/Seat No.
Health Information
Have you experienced any of the following symptoms during the past 14 days?
Fever
Cough
Shortness of Breath
Sore Throat
None of the above
Have you been in contact with anyone diagnosed or suspected of having a communicable illness in the last 14 days?
Yes
No
If yes, provide details
List countries/regions visited in the past 21 days
Declaration
I declare that the information given above is true and complete to the best of my knowledge.
Date
Signature