HEALTH DECLARATION

CORONA VIRUS – SAFETY PRECAUTIONS

1. NAME:

2. SHIP NAME:

3. EMBARKATION LOCATION / DATE

4. DISEMBARKATION LOCATION / DATE

5. Travel history in the last 3 weeks. (Please

indicate countries or ports visited)

6. Have you been self-isolating at home the

last week? If not, pls advise if you have
travelled and/or if you have been in public
places in the last 7 days.
7. Did you have, or display signs of Fever,
chronic cold & cough in the last 3 weeks.

8. Have you tested positive for SARS–CoV-2 or

COVID-19

9. Have you come in close personal contact

with anyone that has displayed signs of
fever, persistent cough, or other symptoms
commonly associated with COVID-19
10. Confirmation that you will adhere and
comply with all shipboard hygiene and
safety measures, implemented to counter
spread of potential Covid-19 virus
infections.

Name / Signature

_________________________________

Date:

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