COVID-19 Screening Questionnaire

Due to the recent COVID-19 outbreak, Northern Marine is implementing additional

precautions to safeguard the health and safety of its employees and visitors.
All visitors to Vessel / Facility must complete the declaration before entry.
In the best interest of all parties, your entry to the vessel / facility will be subject to the
answers provided and the signature of this document.
Completion of this form is a mandatory requirement to gain entry to Northern Marine
Vessel / Facility.

No. Question/Informat Yes No

ion
1 Have you monitored your body temperature during the last 14 days?
2 What was your average body temperature during the last 14 days (…)
3 Do you, or anyone in your household, have any of the Covid-19
symptoms as described by WHO?
4 In the last 14 days, have you knowingly had any contact with anyone
diagnosed with Covid-19?
5 In the last 14 days, have you knowingly visited or stayed with anyone
with Covid-19?
6 In the last 14 days, have you knowingly shared a home environment
with anyone with Covid-19?
7 During your time onboard, will you follow WHO guidelines, Vessel’s
requirements and local regulations to prevent the spread of Covid-
19, including but not limited to hand washing, social distancing etc?
8 Have you been advised of any additional local or ship-specific PPE
requirements prior to boarding?

I declare that the above information provided by me is true. By signing this

document, I hereby consent to Northern Marine collecting and processing the
personal data contained herein solely for the purpose of providing access to the
Company Vessel / Facility.
Your personal data will be secured by Northern Marine at this location and may only be
accessed by Northern Marine personnel on a need to know basis. NMM will keep this data
only as long as deemed necessary after which time the data and form will be destroyed.

Name Date

Signature Company

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