COVID-19 Health Declaration for Ships During Layups

Must be completed every individual

Date: Ship:
Port:  
Name: Crew ID :

To assist us in protecting the health and safety of all persons on the ship, please answer the following questions:

IN THE PAST 14 DAYS, HAVE YOU HAD ANY OF THESE SYMPTOMS:

1. Cough, shortness of breath, difficulty breathing, fever, chills, repeated

shaking with chills, muscle pain, headache, sore throat, or new loss of
YES No
taste or smell?
IN THE PAST 14 DAYS, HAVE YOU:

2. Had contact with a suspected or confirmed case of COVID-19 or a person

under monitoring for COVID-19? YES No

This questionnaire may be reported to the relevant public health authorities. Penalties may apply to any individual
who knowingly and wilfully makes a false, fictitious or fraudulent statement or representation.
I certify that the above declaration is true and correct and that any dishonest answers may have serious public
health implications.

Signature:

For Official Use Only: Form Validated:

2020-05-01 ver0
(All– COVID-19)
Initials: