INTERNATIONAL CRUISE SERVICES, SOCIEDAD LIMITADA 1

Calle 50, Edificio Global Bank, Piso 16 Oficina D, Panamá, Panamá

SEAFARER’S HEALTH SELF-DECLARATION WITH COVID-19 PCR RT TEST

Dear Seafarer:

Seafarers that successfully passed the PEME are required to complete the Seafarer’s Health Self-Declaration with COVID-19 PCR RT test
form and submit it to the Company 72 hours prior to deployment.
Instructions for all crew joining a vessel:
 Comply with all infection protection and control precautions such as social distancing as well as hygiene precautions (e.g. wash
hands, avoid touching face), use of Personal Protection Equipment (face mask/covering and gloves)
 Avoid contact with persons who show or are believed to have COVID-19 Symptoms (e.g. Cough, Fever, etc.).
 Promptly inform the Company, your hiring agent if you are suffering or you suspect having symptoms of COVID-19.
 You must keep the original form and any record with you until you board the vessel where it will be collected. You should not
store this form and records in your check-in luggage. We suggest you keep this form with your passport and vaccination card.
 You will not be eligible for Deployment if you have a fever, flu like symptoms or COVID-19 symptoms.
 Your Deployment COVID-19 PCR test must be done within 72 hours of joining the assigned vessel. Only negative COVID-19 PCR
RT test results done within this period of time will be accepted to clear you for travel to the port destination.
 This Form including the COVID-19 PCR RT results must be sent to the PEME Controller assigned to the vessel you are joining.

Special Instructions

With the rapid spread of the Omicron variant of the COVID-19 virus, the United States of America revised its travel restrictions for all
international travelers. Effective December 6, 2021, all international travelers travelling to the United States of America must show a
negative COVID-19 Viral Test that has been administered and results presented within 24 hours of the departure to the United States. In
other words, you will need to do a COVID-19 Antigen Test within 24 hours before commencing your travel to the United States. This is a
second test. You do not need to submit this test results to the PEME Controller but you must present the official COVID-19 Antigen test
results from the license healthcare provider to the airline upon Check-In at the airport. You will also need this second test document
when you arrive to the United States and when joining the vessel.

COVID-19 PCR RT TEST RECORD- THIS TEST IS REQUIRED TO BE ADMINISTERED WITHIN 72 HOURS PRIOR TO DEPLOYMENT.
CONSENT TO COVID-19 TESTING Yes / No
I consent to be tested for COVID-19 (a/k/a SARS-CoV-2) at any time during my employment. I consent to have the results revealed
to my Employer, my manning agent, the ship-owner, ship operator, their agents, and affiliates. If “no” please provide a detail
explanation on a separate sheet. I understand my deployment will be delayed or cancelled pending review of my explanation.
Test Type Date Taken Date Results Test Manufacture Result (select from menu)
COVID-19 PCR RT

COVID-19 PERSONAL HISTORY

Have you ever tested positive COVID-19? No or Yes.
If “yes”, please provide the date of the last positive test and name of the test:

Positive Test Date (dd/mm/yyyy) ________________ Name of Test done: _____________________

Please note that if you tested positive for COVID-19 during the last 90-days, your deployment may be adjusted accordingly.

I confirmed the information provided in this pre-joining form is accurate and correct. I am signing my name below in agreement that my employer or
shipowner can terminate my employment should I or my representative, including my manning agent and doctors, be found to have lied,
misrepresented or falsely provide information in this form including any documents that may be attached.

Seafarer’s Signature: ____________________ Date: ____________

THD | ICS - Rev.: 12032021

 INTERNATIONAL CRUISE SERVICES, SOCIEDAD LIMITADA 2
Calle 50, Edificio Global Bank, Piso 16 Oficina D, Panamá, Panamá

SEAFARER’S HEALTH SELF-DECLARATION

Last name: ______________________________ First name: _________________________________

Employee ID Number: _____________________ Name of Ship: _______________________________

1. Have you received information and guidance on the coronavirus (COVID-19), including about standard health protection
measures and precautions? Yes or No
2. Do you understand and comply with applicable standard health protection measures and precautions to prevent the spread of
the coronavirus (COVID-19), such as proper hand washing, coughing etiquette, appropriate social distancing? Yes or No
3. Have you ever tested positive for COVID-19 within the past 90-days (3 months)? Yes or No.
Please note that your vaccination date and/or travel to the ship may be adjusted accordingly.

During the last 14-days, have you:

4. Tested positive for being infected with the coronavirus (COVID-19)? Yes or No
If “yes”, please provide the date of the test and name of the test:
Positive Test Date (dd/mm/yyyy) _________________________ Name of Test done: ___________________________________

5. Tested positive for the antibodies for the coronavirus (COVID-19)? Yes or No
If “yes”, please provide the date of the test and name of the test:
Positive Test Date (dd/mm/yyyy) _________________________ Name of Test done: ___________________________________

6. Shown any symptoms associated with the coronavirus (COVID-19), specifically,

Fever: Yes or No Headaches Yes or No
A dry cough: Yes or No Conjunctivitis Yes or No
Tiredness: Yes or No Chest Pain Yes or No
Aches and Pains Yes or No Loss of Speech Yes or No
Sore Throat: Yes or No Difficulty Breathing Yes or No
Diarrhea: Yes or No Shortness of Breath Yes or No
Nausea: Yes or No Skin Rash Yes or No
Loss or change in taste/smell Yes or No

7. Completed a period of self-isolation related to coronavirus (COVID-19)? Yes or No

If “Yes”, please explain the circumstances and the length of self-isolation.

8. Had close contact with anyone that has tested positive for coronavirus (COVID-19)? Yes or No
(“Close Contact” means being at a distance of less than one meter for more than 15 minutes.)

9. Had close contact with anyone with symptoms of coronavirus (COVID-19)? Yes or No
(“Close Contact” means being at a distance of less than one meter for more than 15 minutes.)

10. Maintained good personal hygiene and complied with applicable health protection measures and precautions? Yes or No

I confirm the information provided above is true and correct to the best of my knowledge.

Seafarer’s Signature: ____________________ Date: _______________________________

 If you answer “yes” to Questions 4 to 9 of the Seafarer’s Health Self-Declaration, then your deployment must be postpone
pending further inquiry/investigation
THD | ICS - Rev.: 12032021