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Seafarer Health Declaration Form

The seafarer health declaration form collects information from seafarers about their health and recent travel history. It asks whether they have symptoms like fever or cough, lists countries visited in the last 14 days, and whether they have been in contact with someone with COVID-19 or visited a hospital. The seafarer must sign to declare the information is true and correct.

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Johanna Catalan Cantones
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90 views1 page

Seafarer Health Declaration Form

The seafarer health declaration form collects information from seafarers about their health and recent travel history. It asks whether they have symptoms like fever or cough, lists countries visited in the last 14 days, and whether they have been in contact with someone with COVID-19 or visited a hospital. The seafarer must sign to declare the information is true and correct.

Uploaded by

Johanna Catalan Cantones
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Annex – Health Declaration Form

Seafarer Health Declaration Form


Name: Ship’s name:

1. Do you have any of the following flu-like symptoms?

Fever Yes No

Cough Yes No

Breathlessness Yes No

Sore throat Yes No

Running nose Yes No

Muscle joint pain Yes No

Chest pain Yes No


Others: please specify:

2. List the countries that you have been in during the last 14 days From To
1.
2.
3.
4.
5.

3. Did you come in close contact with any person suffering from
COVID-19 in the last 14 days? Yes No

4. Have you ever been admitted to or visited a hospital in the


past one month? Yes No

If yes, please specify the reason for the admission or visit:

5. Have you been in contact with farm or non-domesticated


Yes No
animals in the past one month?

6. Declaration: I hereby declare that, to the best of my knowledge the information


provided is true and correct

Signature: Date:

The personal data contained in this form will be used solely for the purpose of compliance with legal/statutory
requirements of port and other authorities. The personal data will be stored and processed by the operator in
accordance with any applicable data privacy laws.

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