Offshore Platform Health Declaration
Personal Information
Full Name
Date of Birth
Position/Job Title
Employee ID
Contact Number
Offshore Platform Name
Recent Health Status
Have you experienced any of the following symptoms in the past 14 days? (Check all that apply)
Fever
Cough
Shortness of breath
Sore throat
Other Symptoms
Medical History
Do you have any chronic illnesses? If yes, specify.
Are you currently taking any medication?
Recent Travel History
Have you travelled outside the country or been in contact with anyone who has tested positive for an infectious disease in the past 28 days?
Yes
No
If yes, please provide details
Declaration
Name
Date
Signature