HEALTH DECLARATION FOR JOINING CREW MEMBERS

Ship       Join Date 08/0 (e.g. 01-Sept-2015)

Family Name Bukri

      First Name Griseld
     
ID Number J50923077I
      Rank      

Dear Crew Member,

In order to protect your health and that of your fellow crew and guests onboard, please complete this declaration
completely, accurately and honestly. The information will be reviewed by the shipboard Medical Staff who may
contact you to provide further details.
Thank You,
Medical Staff

SECTION 1:
Have you had any of the following symptoms within the past three (3) days?
SYMPTOM NO YES * * IF YES, DATE SYMPTOM STARTED
1) Diarrhea (loose stools) 06/1

2) Vomiting (nausea) 06/1

3) Abdominal Pain or Cramps 06/1

SECTION 2:
Do you have any of the following symptoms?
SYMPTOM NO YES * * IF YES, DATE SYMPTOM STARTED
4) Fever or Feverishness 06/1
5) Sore Throat 06/1
6) Runny Nose 06/1
7) Cough 06/1
8) Headache 06/1
9) Muscle Aches 06/1
10) Skin Rash 06/1
11) Yellow Eyes or Dark Urine 06/1

SECTION 3:
12) Are you currently taking any prescription medications such as pills,
NO YES
inhalers, or injections?
13) During your leave, did you consult a doctor or were you treated, or
NO YES
hospitalized for any illnesses?

I certify that this medical declaration is a true, accurate and complete statement. I understand that any false or
misleading statement or deliberate concealment of facts may have significant public health consequences and
may also result in the withdrawal of my Seafarer Medical Fitness Certificate and/or lead to my dismissal.
I understand that my obligation to completely and accurately disclose any current or pre-existing medical condition
in this declaration is mandatory, and that my failure to do so may cause me to forfeit any or all medical, wage and/
or any other related allowances or benefits to which I might otherwise be entitled in the case of illness or injury. If
I feel ill, I understand that I am to report illness to the Medical Center and to my supervisor immediately. Failure to
or delay in reporting illness may result in disciplinary action up to and including termination.
I consent to the full disclosure by any medical personnel, health care worker or facility of any health
information and/or related records of any kind to the Company Medical Department concerning my past,
present or future medical condition.

Signature: Date: Jan 04,2020

08/0

Crew Health Declaration_2015-09 ver0