Appendix 3 – Isolation Declaration (version 5)

Prior to travelling to embark / disembark the vessel it is the seafarer’s responsibility to complete and return
the below to your Crewing Officer.

You will not be permitted to join the vessel if you have experienced symptoms or have failed to self- isolate
for the required period prior to travel.

On completion and return of this form you must remain in self isolation until travelling.

The safety and wellbeing of our crew is on board is paramount. Failure to comply with company instruction
regarding the COVID-19 pandemic may result in disciplinary action.

Date
Name
Rank

1) Have you been in self isolation for the period requested by your crewing officer/manning
office prior to travelling to the vessel? (On signer only)

Yes V
No ⬜

If no please state the reasons you did not complete the isolation, the length of time and
occasions you left home and whether safety precautions were taken such as (social
distancing, face mask, handwashing etc)

2) Have you tested positive for being infected with the coronavirus (COVID-19)?

Yes ⬜
No V

If yes, please provide date and name of test:

3) Have you tested positive for the antibodies for the coronavirus (COVID-19)?

Yes ⬜
No V

If yes, please provide date and name of test:

4) Have you had close contact with anyone that has tested positive for coronavirus (COVID-
19)?
(Close contact means being at a distance of less than one meter for more than 15 minutes.)

Yes ⬜
No V

If yes, please provide details of when:

5) Have you been experiencing any of the following symptoms in the last 14 days?

Fever ⬜ Shortness of breath ⬜

Chills ⬜ Muscle aches ⬜
Cough ⬜ Vomiting ⬜
Sore Throat ⬜ Diarrhea ⬜
Loss of smell and taste ⬜

6) Have you maintained good personal hygiene and complied with applicable health
protection measures and precautions?

Yes V
No ⬜

7) Do you agree that recent temperature checks prior to off sign have been normal? (off
signer only)

Yes ⬜
No ⬜
 P recautions to take while in isolation / travelling to / from the vessel:

● Cover your mouth and nose with a tissue or your sleeve (not your hands) when you cough or sneeze
and put used tissues in the bin immediately
● Wash your hands with soap and water often – use hand sanitiser gel if soap and water are not
available
● Try to avoid close contact with people who are unwell
● Do not touch your eyes, nose or mouth if your hands are not clean
● Clean and disinfect frequently touched objects and surfaces
● Do not travel if you have any symptoms of this virus. Liaise closely with your manning office and
always be honest with the company.
● Northern Marine will, where we can, arrange for a Nasal/Throat swab test to be completed prior
leaving home. This is the molecular test and will give a result in a couple of days.
● Face mask to be worn whilst travelling – AT ALL TIMES – do not remove unless to change the mask.
● Wear hand covering – gloves as is appropriate but remember that gloves can become
contaminated the same as your hands. Frequent washing is key.
● Throughout the process of embarkation, seafarers must maintain social distancing with a minimum
of 2 metres between themselves and another person.
● No hand shaking or other physical contact must be permitted throughout the transfer period.
● Travel with a small bottle of antibacterial hand cleanser.
● Seafarers should maintain hand hygiene through hand washing or use of hand sanitiser -
recommended interval 20 minutes where possible. Most important to wash hands after going
through airport security and touching surfaces etc.
● Be attentive to avoid touching your face, nose and eyes where at all possible
● Seafarers should also carry their own pens and personal effects so that they do not need to share.
● Carry your own food, water, etc, from your home, which has not been touched by others. This will
avoid you using roadside and airport cafes where there is an increased risk of infection.
● If a taxi is required. Please ensure you sit in the back seat with window down and away from the
driver and mask is kept on at all times.

Name:

Signature: …………………………………………………