Declaration of Travel History of seafarer (past 28 days) Annexure - I

Name Indos No.

Last sign off date Passport No.
Last sign off port / country

Approx. time Name of the

Details / address of place visited (Home, Friend, Hotel, Social gathering, Hospitals Contact details (phone
S. No. Date of visit to person(s) you met
etc.) no.) of person(s) met
place(s) Hrs with

I / we, do hereby declare that above particulars of information and facts stated are true, correct and complete to the best of my knowledge and belief.

Place:
Date: Name / Sign.
 DAILY CREW TEMPERATURE CHECK RECORDS

Name of Seafarer:

Indos No:

CDC or Passport no:

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

Check 1 Check 2
SN Date
Temperature Time * Temperature Time *
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28

* Temperature may be recorded in degrees Celsius or Fahrenheit.

I do hereby declare that above particulars of information and facts stated are true, correct and
complete to the best of my knowledge and belief.

_____________________________________________
Date: Name of seafarer & Signature