Seafarer Travel Health Self-Declaration Form
Personal Information
Full Name
Rank/Position
Nationality
Date of Birth
Passport No.
Contact Number
Travel Information
Ship Name
IMO Number
Joining Date
Joining Port
Health Declaration
Cough
Fever
Shortness of breath
Sore throat
None of the above
Recent Travel History
Countries/places visited in last 14 days
Exposure Declaration
Yes
No
If yes, please provide details
Declaration & Signature
Name & Signature
Date