THE COVID-19 FORM

Fill in this form and the COVID-19 form 2.

Questions related to the novel Coronavirus (COVID-19)

Has there been a crewmember/passenger change at the last 10 (ten) ports within the last 14 (fourteen) days?

If yes, at which port did the crewmember or passenger embarked? (please mention embarkation and passport information in the COVID-19 form (2) also)

Has any crewmember or passenger on board visited a healthcare facility where patients with COVID-19 are being treated?

Has any crewmember or passenger on board been in contact with someone from a COVID-19 affected country with the following symptoms within the past 14 days?

Fever

Cough

Sore throat

Runny nose

Shortness of breath

Headache

Fatigue

None of the above

Has any crewmember or passenger on board been in contact with someone who has been diagnosed with COVID-19?

If “YES” please provide name (s)

Has any crewmember and/or passenger on board had the following symptoms over the past 14 days?