Traveler’s Health Declaration Questionnaire

Rev: 2.01 Date: 16/09/2021 Doc ID: HSE 424 Page: 1

Doc Type: Template Doc Owner: HSEQ Manager

Traveler’s Health Declaration/Questionnaire

(to be completed prior to boarding by all persons and sent to the Master onboard)

Date: _____________

Ship: _____________

Port: _____________

Name (as shown in passport): __________________________________

To assist us in protecting the health and safety of all crew onboard this LNGc/FSRU/ we require you
to answer the following questions:

1. If you have been traveling outside this Country/Territory/State, the last 3 weeks please state
which Country/Territory/State and travel dates below:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

2. Have you had close contact with, or helped care for, anyone suspected or diagnosed as having
Novel Coronavirus, or who is currently subject to health monitoring for possible exposure to
Novel Coronavirus? Y / N
a) If YES, when __________________

3. Do you have a fever (100.4 F° / 38 C° or higher), feel feverish, or have chills, a cough or
difficulty breathing? Y / N

4. If you have gone or will go through a screening at another location prior embarking what kind
of screening have you gone through and when?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

The information in this questionnaire will be used onboard to evaluate if access to the vessel/FSRU will
be granted or not. The information may also be reported to the relevant public Health Authorities.

Penalties may apply to any individual who knowingly and willfully makes a false, fictitious or fraudulent
statement or representation.

I certify that the above declaration is true and correct and understand that any dishonest answers may
have serious public health implications.

Signature: ___________________________________

File document as specified in QA 203 when complete