Stay Home Record Pre-Joining Declaration / Questionnaire
The declaration is to be completed by ALL crew members joining the vessel.
Rank
Full name
Nationality
Passport No: / Seaman book no
Full style Address with State /
Country
Questions
Within the last 14 days: Yes No
Did you had Fever (more than 37.5 C) or Flu symptoms extending for 3 to 4
days?
Did you have persistent Cough / Breathing difficulties?
Have you suffered from Coronavirus disease (COVID -19) ?
Have you been in contact with anyone who has have symptoms of Flu or
COVID19 ("Close contact" means being at a distance of less than one meter for
more than 15 minutes?)
Have you been in contact with anyone who recently arrive from the countries
listed by National Centre for Disease Control ?
Have you ever been admitted to or visited a hospital in the past one moth?
If yes, please specify the reason for the admission or visit:
Temperature log:
Temperature (In Celsius)
Day Date 1000 hrs (LT) 1500 hrs (LT)
1
2
3
4
5
6
7
8
9.
10
11
12
13
14
OFC04 App2 (05/2020)
VERIFICATION DETAILS
Manning office staff
Date Verification method Remarks
carried out verification
I hereby declare that during my travelling to vessel by plane/car/train I do confirm that have fully
understand that need to comply 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 & mandatory to use face mask at all time and use antiseptic liquids.
_______________________ ________________________
Signature of seafarer Name & Signature of Manning office PIC
Name: Manning Office Name:
____________________
Date: Date:
The personal data contained in this form will be used solely for the purpose of compliance with
legal/statutory requirements of port and other authorities. The personal data will be sorted and
processed by the operator in accordance with any applicable data privacy laws.
OFC04 App2 (05/2020)
Covid Precaution Checklist
Covid test: Covid PCR test to be done within 72 hours of travel or earlier as per flight requirement
Joiners must hand carry below items with them while leaving home for joining vessel and
expense will be reimbursed to them with supporting receipts:
1. Face masks (minimum 15 no's)
2. Hand gloves (minimum 5 no's)
3. Face shield (2 no's)
4. Digital Thermometer (same like home use, not more than USD 20)
5. Hand Sanitizer (small) – 2 no's
Checklist for Travel to Ensure Social Distancing during Covid Pandemic:
1. During visit to Office / clinic / Embassy (if required) / while joining please use single
transport.
2. NOT to meet other joiners Socially
3. Strictly maintain Social distance until arrive onboard
4. If any Hotel stay at seaport, should NOT go out from the room.
Taxi
1. Must use one Taxi per person
2. Always ask the Cab driver to put the required PPE
3. Always take a receipt
4. Take a photo of the Taxi Registration plate
5. Take photo of the Taxi
6. Take a selfie photo in the Taxi to confirm you are sitting alone
Medical
1. Difference between one person of same group and the other should be 30 mins at Medical and
COVID test centre.
2. Take selfie photo of you sitting and maintaining safe distance with others at COVID center and
Doctor Clinic
3. Minimize your time at Medical Centre and COVID Centre
OFC04 App2 (05/2020)
In the Aircraft, Transit Area and Lounge
1. NOT to move in groups, always maintain social distance of 2 meters with others.
2. Do NOT Check-in at the same time with other joiners at Airport counter
3. Try NOT to have plane seats adjacent to each other with other joiners.
4. Always be seated inside the Aircraft, NOT move around inside the Aircraft.
5. Take photo of you boarding plane
6. Take photo of you sitting on the plane seat.
7. Take photos of you coming out of Plane
8. Take photo of you maintaining Social distance once every 2 hr while in longue or transit area.
Important Note
Share photos of documents and yours with the MO Personnel on the WhatsApp group created
Please ensure that you wear the PPE at all times and it should be clearly seen in your selfies
DO NOT go for any shopping inside the Airport. Always be seated, next to your designated
boarding Gate
Remarks: Any deviation from above has to be approved in writing from FPD Manager by respective
Office Manager.
_______________________ ________________________
Signature of seafarer Name & Signature of Manning office PIC
Name: Manning Office Name:
____________________
Date:
OFC04 App2 (05/2020)
