Pre-Embarkation Coronavirus Checklist

Visitor’s required information

General information about the vessel (to be completed by the vessel)

Vessel Name: STOLT KIRI Port of Call:

Date of embarkation of
Name of visitor/ new joiner: LONDON G. ARBUIS visitor/ new joiner
Reason of Embarkation:

• Please reply to the below information as this is part of the onboard COVID-19 precautionary onboard
plan.
• This form shall be sent to the vessel (through the local agent) or shall be given to the deck officer in
charge at the embarkation point.
• Please be advised that for Health reasons and in case it is required the Master or the Officer in charge
may not allow to embark the vessel.

Questions for visitor/ contractor prior embarkation Yes/ No Action taken

1. Have you had any close contact with individual/s suspected or diagnosed No
with Coronavirus in the last 14 days?
2. Have you travelled to any of the affected areas within the last 14 days? No
If yes, please elaborate
3. Have you experienced any dry cough, fever or breathlessness the last No
few days?
4. Are you experiencing any ill health / pre-existing health No
conditions(diabetes, heart disease, High Blood Pressure etc) that would
make you more sensitive to COVID-19?
5. Do you have available PPE for the virus (e.g. masks, goggles, gloves Yes
etc.)?

Signed by visitor/ new joiner

Supplementary Comments

*The above data will be treated in strict confidentiality and will be stored in a secure location with limited
access, as part of risk assessment evaluation.
*Company is totally consistent and aligned with Corporate Social Responsibility (CSR) key values, conducting
business under an ethical manner.

Issued 18th Mar 2020

Document ID Version Document Owner Approved by Page Number

Pre-Embarkation
0 AFO MFM Page 1 of 2
Corona Checklist
Pre-Embarkation Coronavirus Checklist

1.0 Revision Record

Revision No.
Rev. No. Date Section Remarks

Document ID Version Document Owner Approved by Page Number

Pre-Embarkation
0 AFO MFM Page 2 of 2
Corona Checklist