COVID-19 CREW DECLARATION FORM

Name of the Crew:

Rank:

Current Address:

Sr. Information Declaration

No.
1 When did you last sign off? (specify date, ship
name and port where you signed off)
2 Mention places you visited in last 1 month.
3 Is your current residential area declared as
COVID-19 containment zone by the authorities?
Furnish details of containment zone.
4 Is your building/ society have been quarantined
due to a positive person residing in your building/
society.
4 Have you or your close contacts being tested?
(Specify date and result)
5 Have you or your family member been
quarantine in any of the public quarantine facility
in last 1 month? (Y/N)
6 Have you or your family member having
symptoms like fever, sneezing, cough and
running nose? (Y/N)
8 Have you travelled together with COVID-19
patient in any kind of conveyance? (Y/N)
Have you lived in the same household as a
9
COVID-19 patient? (Y/N)
10 Are you having any other medical issue
currently?
1. Please carry your own mask, gloves and tissues. Wear COVID-19 PPE properly before
boarding the ship.
2. Please keep a daily record of your body temperature till joining the ship.

Date: