Pre-boarding Health Declaration Questionnaire
DATE AND TIME OF INITIAL PORT OF INITIAL VESSEL’S No OF
VESSEL’S NAME
EMBARKATION EMBARKATION REGISTRY
Contact telephone number for the next 14 days after disembarkation
First Name as shown in the Surname as shown in the
Father’s name
Identification Card/Passport Identification Card/Passport
First Name of all children travelling Surname of all children travelling
Father’s name
with you who are under 18 years with you who are under 18 years
QUESTIONS
Within the last 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 room/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?
No
8. Have you been tested for COVID-19 with a molecular method (PCR) within the Pending results
past 72 hours? Positive
Negative
No
9. Have you performed, this day or the day before, a rapid test for COVID-19? Positive
Negative
No
10. Have you been vaccinated with all the necessary doses for COVID-19?
Yes
