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Name of The Crew:: Sr. No. Information Declaration 1 2 3

This document is a COVID-19 crew declaration form asking for information from crew members such as when they last signed off from a ship, places visited in the last month, whether their residential area or building has been quarantined, if they have been tested or quarantined, and if they are experiencing any COVID-19 symptoms. It concludes by asking the crew member to take safety precautions by bringing their own protective equipment and monitoring their temperature until joining the ship.

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Prakash Ratnani
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148 views1 page

Name of The Crew:: Sr. No. Information Declaration 1 2 3

This document is a COVID-19 crew declaration form asking for information from crew members such as when they last signed off from a ship, places visited in the last month, whether their residential area or building has been quarantined, if they have been tested or quarantined, and if they are experiencing any COVID-19 symptoms. It concludes by asking the crew member to take safety precautions by bringing their own protective equipment and monitoring their temperature until joining the ship.

Uploaded by

Prakash Ratnani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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COVID-19 CREW DECLARATION FORM

Name of the Crew:

Rank:

Current Address:

Sr. Information Declaration


No.
1 When did you last sign off? (specify date, ship
name and port where you signed off)
2 Mention places you visited in last 1 month.
3 Is your current residential area declared as
COVID-19 containment zone by the authorities?
Furnish details of containment zone.
4 Is your building/ society have been quarantined
due to a positive person residing in your building/
society.
4 Have you or your close contacts being tested?
(Specify date and result)
5 Have you or your family member been
quarantine in any of the public quarantine facility
in last 1 month? (Y/N)
6 Have you or your family member having
symptoms like fever, sneezing, cough and
running nose? (Y/N)
8 Have you travelled together with COVID-19
patient in any kind of conveyance? (Y/N)
Have you lived in the same household as a
9
COVID-19 patient? (Y/N)
10 Are you having any other medical issue
currently?
1. Please carry your own mask, gloves and tissues. Wear COVID-19 PPE properly before
boarding the ship.
2. Please keep a daily record of your body temperature till joining the ship.

Date:

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