Small Craft Maritime Health Self-Certification
Personal Information
Full Name
Date of Birth
Nationality
Passport/ID Number
Vessel Information
Vessel Name
Registration Number
Health Status
I am fit for duty and capable of performing assigned tasks.
I do not have symptoms of illness (fever, cough, shortness of breath, etc.).
I am not taking any medication affecting my ability to operate a vessel safely.
I do not have any medical condition that may affect my maritime duties.
Declaration
I confirm that the above information is true and complete to the best of my knowledge.
Signature
Date