1 [Update:24-3-2020]

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