FORM

JDNS.SF.08.75.e
PRE-ARRIVAL CHECKLIST COVID-19 REVISION 03

PERSONAL INFORMATION
Name and Surname:
Company Country of Origin + Address where your are staying Reason for presence on site:
Home Address in the country of employment
JAN DE NUL N.V. /
MRA OFFSHORE VESSEL: (VESSEL NAME)
SIGN ON CREW
CORPORATION

QUESTIONNAIRE:
QUESTIONS COMMENTS
1 Have you been in contact with a confirmed or probable COVID-19 case in the past 14
days? If so, please specify when and where in the comment section.
YES – NO*
2 Have you stayed in your home town for the last 14 days? If not, please also state your
travel history in the comment section.
YES – NO*
3 Are you feeling ill/ have a cold/ runny nose/ inflammation of the upper respiratory
system/ flue symptoms? If yes, please specify in comment section.
YES – NO*
4 Are there any sick persons in the family? If so, please specify in the comment section.
YES – NO*
5 Have you been vaccinated for COVID-19? If so, please specify with which vaccine and
when you received the last dose. Please provide a copy of the vaccination certificate.
YES – NO*
*circle the correct answer. If any of the answers to above questions change between completion of the form and arrival on site, please notify the project management immediately!

I declare that the information provided is true and correct. Date and signature
I agree to possible COVID-19 testing and I confirm that the results can be shared with JDN.

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 FORM
JDNS.SF.08.75.e
PRE-ARRIVAL CHECKLIST COVID-19 REVISION 03

TEMPERATURE REGISTRATION
DATE READING (°C) DATE READING (°C)
1. Morning: 8. Morning:
Afternoon: Afternoon:
2. Morning: 9. Morning:
Afternoon: Afternoon:
3. Morning: 10. Morning:
Afternoon: Afternoon:
4. Morning: 11. Morning:
Afternoon: Afternoon:
5. Morning: 12. Morning:
Afternoon: Afternoon:
6. Morning: 13. Morning:
Afternoon: Afternoon:
7. Morning: 14. Morning:
Afternoon: Afternoon:

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