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2020]
KOH SICHANG QUARANTINE OFFICE, THAILAND
Questionnaire for Coronavirus Disease 2019 Screening

Date of arrival :………..……………………………….

Name of Ship : ………………………………….……

IMO Number : ……………….……………….………

Number of Crew :……………………………………...…

Last Port of call : …………………………….….……… Country: …………….…………..………

Next port : …....……….…………….…………… Country: …………..………………….…

1. Within the last 14 days, have you or your crews traveled to any of the Coronavirus Disease 2019

(COVID-19) affected countries?

 China  Hong Kong  Macao  Italy  Iran

 South Korea  Austria  Belgium  Malaysia  Canada

 Portugal  Brazil  Czech  Israel  Australia

 Germany  Ireland  Pakistan  Finland  Turkey

 Greece  Chile  Luxemburg  Poland  Ecuador

 Switzerland  France  Spain  USA  Norway

 Denmark  Netherland  Sweden  UK  Lao

 Indonesia  Myanmar  Cambodia

 Japan [Hokkaido, Tokyo, Aichi, Wakayama, Kanagawa, Chiba, Okinawa, Kyoto, Osaka]
 The other countries has local transmission.

 Yes.  No.

Name of port : …..….……… Country: ………….…… Date of departure : ………………

Name of port : …..….……… Country: ………….…… Date of departure : ………………

Name of port : …..….……… Country: ………….…… Date of departure : ………………

Name of port : …..….……… Country: ………….…… Date of departure : ………………

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2. Which of the following symptoms have you or your crews experienced within the last 14 days?

 Fever ≥ 37.30c  Cough  Difficulty breathing

 Runny nose  Sore throat  No symptoms.

3. Please advise the required document with the reply.

- Maritime Information of Health.
- Maritime Declaration of Health.
- The voyage memo (last ten ports).
- The crew list with embarked date & place.
4. Record everyone’s body temperature once a day for at least 7 days prior to port arrival.

Body temperature (Degree Celsius)

Name of
No. Date Date Date Date Date Date Date
Captain & Crew
……... ……... ……... ……... ……... ……... ……...

Remark: Use extra sheet(s) for temperature records, if necessary.

I hereby certify that the above statements are true.

Signature …………………………………………
Captain / Master of the Ship
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