COVID-19 Maritime Crew Health Declaration
Crew Member Information
Full Name
Rank/Position
Date of Birth
Nationality
Passport/Seaman’s Book Number
Vessel Information
Vessel Name
IMO Number
Port of Arrival
Date of Arrival
Health Status
Have you had any of the following symptoms in the past 14 days? (Check all that apply)
Fever
Cough
Shortness of Breath
Sore Throat
None of the above
Other symptoms or details
Exposure
Have you been in contact with a confirmed COVID-19 case in the past 14 days?
Yes
No
Have you visited any country with reported COVID-19 cases during the past 14 days?
Yes
No
If YES, list countries and dates of visit
Vaccination
Have you been vaccinated against COVID-19?
Yes
No
If YES, provide vaccine name and date(s) of vaccination
Additional Comments
Declaration:
I hereby declare that the information provided above is true and complete to the best of my knowledge.
Crew Member Signature
Date