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    Preliminary Checklist - Covid 19 - Molmi

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    Rohit Patel
    MOLMI is requiring all seafarers to complete a self-declaration form to check for potential COVID-19 exposure and symptoms. The form asks for personal details and has questions about symptoms, recent travel history, contact with infected individuals, hospital visits, social gatherings, and contact with animals in the last 30 days. Seafarers must declare that the information is true and continue daily temperature monitoring, reporting any fever over 37.5 degrees Celsius.

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    Preliminary Checklist - Covid 19 - Molmi

    Uploaded by

    Rohit Patel
    30 views2 pages
    MOLMI is requiring all seafarers to complete a self-declaration form to check for potential COVID-19 exposure and symptoms. The form asks for personal details and has questions about symptoms, recent travel history, contact with infected individuals, hospital visits, social gatherings, and contact with animals in the last 30 days. Seafarers must declare that the information is true and continue daily temperature monitoring, reporting any fever over 37.5 degrees Celsius.

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    MOLMI is requiring all seafarers to complete a self-declaration form to check for potential COVID-19 exposure and symptoms. The form asks for personal details and has questions about symptoms, recent travel history, contact with infected individuals, hospital visits, social gatherings, and contact with animals in the last 30 days. Seafarers must declare that the information is true and continue daily temperature monitoring, reporting any fever over 37.5 degrees Celsius.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    30 views2 pages

    Preliminary Checklist - Covid 19 - Molmi

    Uploaded by

    Rohit Patel
    MOLMI is requiring all seafarers to complete a self-declaration form to check for potential COVID-19 exposure and symptoms. The form asks for personal details and has questions about symptoms, recent travel history, contact with infected individuals, hospital visits, social gatherings, and contact with animals in the last 30 days. Seafarers must declare that the information is true and continue daily temperature monitoring, reporting any fever over 37.5 degrees Celsius.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    PRELIMINARY CHECK AGAINST COVID-19

    Due to the ongoing and rapidly changing situation with the COVID-19, we are requiring all seafarers to fill-out the self-declaration form below.
    Each seafarer must complete this form and is required to send it to the concerned person in charge at MOLMI. This checklist is provided to help
    individuals assess their exposure and limit the risk of spreading the Covid‐19 Virus. This is not intended to be an exhaustive list of symptoms or
    exposures, but to assist in self‐declaring one’s physical condition.

    Date: Emp. No. Name:

    Rank: Age: Passport No.:

    Questionnaire
    1. Do you / family member(s) currently have, or have had, the following symptoms at any time within past 30 days?
    Condition Yes No Condition Yes No Condition Yes No
    Fever**   Running nose   Chest pain  
    Cough   Muscle / joint pain   Headache  
    Shortness of Breath /   Sore throat  
    Breathlessness
    If other than above, please specify;

    2. Have you / family member(s) at your residence travelled from foreign country in the last 30 days? If Yes, List the countries that you/ family
    member(s) have visited?
    Name Relation Name of Country Date of Arrival Date of Departure

    3. Have you travelled outside (domestic) within past 30 days? If Yes, List the cities that you/ family member(s) have visited?
    Name Relation Name of City Date of Arrival Date of Departure

    4. Have you / family member(s) advised by authorities to be self-quarantined?


     Yes /  No

    5. Have you / family member(s) tested for COVID-19?


     Yes /  No. If Yes, result was  Positive  Negative

    6. Was your residence complex/area sealed for containment by Government, within past 30 days?
     Yes /  No

    7. Did you/ family member(s) come in close contact with anyone diagnosed as having COVID-19, within past 30 days?
     Yes /  No

    8. Have you/ family member(s) ever been admitted to or visited a hospital in the past 30 days?
     Yes /  No If yes, please specify the reason for the admission or visit: __________________________________________

    9. Did you / family member(s) attend any social gathering/function within past 30 days?
     Yes /  No

    10. Have you been in contact with farm or non-domesticated animals in the past 30 days?
     Yes /  No

    11. Were you taking due care based on advisory by the govt from time to time?
     Yes /  No

    12. Remarks if any,

    ______________________________________________________________________________________________________

    Declaration:
    1. I hereby declare that, to the best of my knowledge the information provided above is true and correct.
    2** Will continue to measure and record daily log of body temperature and will bring to attention of MOLMI, if temperature crosses 37.5
    degree centigrade.

    MOLMI/REV. 1.0
    PRELIMINARY CHECK AGAINST COVID-19

    ______________________
    Signature

    Disclaimer: The personal data collected in this form will be used solely for the purpose of compliance with legal/statutory requirements. The personal data will be
    stored and processed by the company in accordance with any applicable data privacy laws.

    MOLMI/REV. 1.0

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