Pre-boarding health declaration questionnaire
(The questionnaire is to be completed by all adults before embarkation)
NAME OF VESSEL
SHIPPING COMPANY
DATE AND TIME OF
ITINERARY
PORT OF DISEMBARKATION
Contact telephone number for the next 14 days after
disembarkation:
First Name
as shown in the
Identification
Card/Passport:
Surname as shown in the
Identification
Card/Passport:
Father’s
name:
SEAT
A.ECONOMY
B.AIRCRAFT TYPE
C.BUSINESS
D.CABIN
ΝUMBER OF
AIRCRAFT TYPE
SEAT/ CABIN:
First Name of all
children travelling with
you who are under 18
years old:
Surname of all children
travelling with you who
are under 18 years old:
Father’s
name:
SEAT
A. ECONOMY
B. AIRCRAFT TYPE
C. BUSINESS
D.CABIN
ΝUMBER OF
AIRCRAFT TYPE
SEAT/ CABIN:
Questions
Within the past 14 days
YES
NO
1. Have you or has any person listed above, presented sudden onset of
symptoms of fever or cough or difficulty in breathing?
2. Have you, or has any person listed above, had close contact with
anyone diagnosed as having coronavirus COVID-19?
3. Have you, or has any person listed above, provided care for
someone with COVID-19 or worked with a health care worker
infected with COVID-19?
4. Have you, or has any person listed above, visited or stayed in close
proximity to anyone with COVID-19?
5. Have you, or has any person listed above, worked in close proximity
to or shared the same classroom environment with someone with
COVID-19?
6. Have you, or has any person listed above, travelled with a patient
with COVID-19 in any kind of conveyance?
7. Have you, or has any person listed above, lived in the same
household as a patient with COVID-19?
