Vessel Crew Health Declaration
Personal Details
Full Name
Rank/Position
Date of Birth
Nationality
Name of Vessel
Date of Joining Vessel
Health Information
Fever, cold, cough or sore throat in the past 14 days?
Yes
No
If yes, specify symptoms and dates
Close contact with suspected/confirmed infectious disease patients?
Yes
No
If yes, provide details
Currently under medication?
Yes
No
If yes, list medication
Declaration
I declare that the information provided is true and complete to the best of my knowledge.
Signature
Date