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Pre-Boarding Health Declaration Questionnaire: (The Questionnaire Is To Be Completed by All Adults Before Embarkation)

Pre-boarding health declaration questionnaire (The questionnaire is to be completed by all adults before embarkation)

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96 views1 page

Pre-Boarding Health Declaration Questionnaire: (The Questionnaire Is To Be Completed by All Adults Before Embarkation)

Pre-boarding health declaration questionnaire (The questionnaire is to be completed by all adults before embarkation)

Uploaded by

Sandis
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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 & Surname as shown Number of Aircraft


Father’s name: Seat:
in the identification Card/ Passport: Type Seat/ Cabin:
Α) ECONOMY
Β) AIRCRAFT TYPE
C) BUSINESS
D) CABIN

First Name & Surname of all children


Number of Aircraft
travelling with you who are Father’s name: Seat:
Type Seat/ Cabin:
under 18 years old:
Α) ECONOMY
Β) AIRCRAFT TYPE
C) BUSINESS
D) CABIN

Within the past 14 days have you or has any person listed above: YES ΝΟ

• Presented sudden onset of symptoms of fever or cough or difficulty in breathing? ....................

• Had close contact with anyone diagnosed as having coronavirus COVID-19...........................

• Provided care for someone with COVID-19 or worked with a health care worker
infected with COVID-19?..........................................................................................................

• Visited or stayed in close proximity to anyone with COVID-19?...............................................

• Worked in close proximity to or shared the same classroom environment with


someone with COVID-19? ........................................................................................................

• Travelled with a patient with COVID-19 in any kind of conveyance?........................................

• Lived in the same household as a patient with COVID-19? .....................................................

Very important! Signature


The use of a surgical or tissue mask during boarding/disembarking
and during the trip is mandatory.
.........................

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