PANAMA MARITIME AUTHORITY

CREW HEALTH SELF-DECLARATION FORM

SHIP CREW CHANGES

CREW DATA
Name
Date of Birth
Contact
Place of Ordinary Residence

Medical Certificate to Work Onboard

Data of Issuance
Doctor
Number/Reference
Date of Expiration
Crew Change Type
Joining ship ☐ Leaving ship ☐
If joining ship
Ship Name
IMO Number
Flag State
Position
If leaving ship
Ship Name
IMO Number
Flag State
Position
Have gone on shore leave in the last YES ☐ NO ☐
14 days?
Have you maintained a safe distance YES ☐ NO ☐
from any shore-side personnel that
have boarded the ship in the last14
days?
Have you received information and YES ☐ NO ☐
guidance on the coronavirus (COVID-
19), including about standard health
protection measures and
precautions?

Do you understand and comply YES ☐ NO ☐

with applicable standard health
protection measures and
precautions to prevent the spread
of the coronavirus (COVID-19),
such as proper hand washing,
coughing etiquette, appropriate
social distancing?

If Joining or Leavig a Ship (During the last 14 days, have you)

Tested positive for being infected Yes ☐ NO ☐ If "Yes", please
with the coronavirus (COVID-19)? provide date of test
and name of test

Shown any COUGH Yes ☐ NO ☐

symptoms
associated with FEVER Yes ☐ NO ☐
the coronavirus
(COVID-19)
Completed a period of self-isolation Yes ☐ NO ☐
related to the coronavirus (COVID-
19)?
If "Yes", please explain the circumstances and the length of self-isolation

Had close contact with anyone that Yes ☐ NO ☐

has tested positive for coronavirus
(COVID-19)? ("Close contact" means
being at a distance of less than one
metre for more than 15 minutes.)
Had close contact with anyone with Yes ☐ NO ☐
symptoms of the coronavirus (COVID-
19)? ("Close contact" means being at
a distance of less than one metre for
more than 15 minutes.)
Maintained good personal Yes ☐ NO ☐
hygiene and complied with
applicable health protection
measures and precautions?

Note: I confirm that the information provided above is correct to the best of my knowledge.

Sign

ID Number
Date: