Crew Health Declaration
Name
Rank/Position
Nationality
Date of Birth
Vessel Name
Date
Have you experienced any of the following symptoms in the past 14 days? (Fever, Cough, Sore Throat, Shortness of Breath, Loss of Smell/Taste)
Have you had close contact with anyone with a confirmed COVID-19 diagnosis in the last 14 days?
Yes
No
Please provide details if any health condition reported above:
Signature