Maritime Joint Crew/Passenger Health Statement
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Nationality
Passport/ID Number
Role on Ship
Crew
Passenger
Other
Contact Information
Email Address
Phone Number
Cabin/Room Number
Voyage Information
Vessel Name
Date of Embarkation
Date of Disembarkation
Port of Embarkation
Port of Disembarkation
Health Declaration
Current Health Status
Have you experienced any of the following symptoms in the last 14 days? (fever, cough, sore throat, difficulty breathing, loss of taste/smell, etc.)
Do you have any chronic illnesses?
No
Yes
Are you currently taking any medication?
No
Yes
If yes to any of the above, please provide details
Travel History (Last 14 Days)
List all countries and cities visited in the last 14 days
Have you been in contact with anyone diagnosed with an infectious disease in the last 14 days?
No
Yes
If yes, please provide details
Declaration
Signature
Date