Crew Health Self-Declaration

Date:

Name of Seafarer:

Medical Certificate Reference Number :

Date of Examination :
Date of Expiry :

Crew Change Type: ☐ Joining ship

Joining ship, Place of Ordinary Residence:

(i.e. City/Town, Country)

1 Have you received information and guidance on the coronavirus (COVID-19), Yes/No
including about standard health protection measures and precautions?
2 Do you understand and comply with applicable standard health protection Yes/No
measures and precautions to prevent the spread of the coronavirus (COVID-19),
such as proper hand washing, coughing etiquette, appropriate social distancing,
and use of PPE in specific situations?

During the last 14 days, have you:

3 Tested positive for being infected with the coronavirus (COVID-19)? Yes / No
  If "Yes", please provide date of test and name of test:  
4 Tested positive for the antibodies for the coronavirus (COVID-19)? Yes / No
  If "Yes", please provide date of test and name of test:  
5 Shown any symptoms associated with the coronavirus (COVID-19), specifically:  
  a new and continuous cough: Yes / No
  a fever: Yes / No
  Loss of sense and smell: Yes / No
6 Completed a period of self-isolation related to the coronavirus (COVID-19)? Yes / No
  If "Yes", please explain the circumstances and the length of self-isolation:  
Had close contact with anyone with symptoms of the coronavirus (COVID-19)?
7 Yes / No
("Close contact" means being at less than 1metre distance for more than 15 minutes)
Maintained good personal hygiene, social distancing measures and complied with
8 Yes / No
applicable health protection measures and precautions?

I confirm that the information provided above is correct to the best of my knowledge.

Signature:
Date:

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 DAILY TEMPERATURE CHECK
Symptoms of COVID-19

• Fever (temperature of 37,8⁰C or above) for at least two consecutive days

• Respiratory distress/ Shortness of breath
• Dry cough or sore throat
• Nasal congestion/runny nose
• Body aches
• Tiredness
• Diarrhea
• Loss of sense of smell
• Loss of sense of taste

Note: Incubation time of COVID-19 is 2-14 days

Name of Seafarer:

Date Temp. Do you have any symptoms as stipulated

Day check Temp. Check above?
no. morning evening If Yes – please list the symptoms
experienced

10

11

12

13

14

* Temperature may be recorded in degrees Celsius.

I confirm that the information below is an accurate record of my body temperature taken twice daily.

Signature:

Classification: Internal Page 2 of 2