Global Marine

COVID-19 SELF-DECLARATION

Employee Name: __________________________________ Country of Origin: ____________________

Employee ID Number: ______________________________ Contact No.: _____________________

Vessel Location: __________________________________

Check one of the following reasons for this self-declaration:

☐ Travel Approval ☐ Pre-Quarantine ☐ Post Quarantine (Travel to Vessel) ☐ Yes ☐ No

Have you tested positive for COVID-19 in the last 14 days? ☐ Yes ☐ No

Are you currently feeling any abnormal symptoms possibly related to COVID-19, or
have had any in the last 14 days? ☐ Yes ☐ No
☐ Fever ☐ Shortness of Breath ☐ Difficulty Breathing ☐ Sore Throat ☐ Fatigue
☐ Muscle or Body Aches ☐ Headache ☐ Loss of Taste ☐ Loss of Smell ☐ Runny Nose
☐ Nausea ☐ Vomiting ☐ Diarrhea ☐ Cough

Have you been in close contact within 6 feet (2 meters) for ≥ 15 minutes with
someone having one or more of the above symptoms within the past 14 days or
come in close contact with a confirmed positive COVID -19 case? ☐ Yes ☐ No

Do you meet McDermott (MAO) definition of fully vaccinated?

(i.e. People are considered fully vaccinated: Two weeks after their second dose in a two-dose vaccine series or two
weeks after a single-dose vaccine). ☐ Yes ☐ No

Thank you for providing the above information.

Employee Signature: _________________________________________________ Date: __________

Employee Comments:

COVID-19 Employee Self-Declaration Form Page 1