Health declaration form

VESSEL: YACHT ANNABELLA
VESSEL'S PORT OF REGISTRY/NO OF REGISTRY: PIRAEUS, NP5287

DATE (day/month/year) AND TIME OF INITIAL EMBARKATION

PORT OF INITIAL EMBARKATION

Your Email

Contact telephone numbers for the next 14 days after disembarkation:

Full name as shown in the Identification Card/Passport:

Father’s name:

Full names including father's name of all children travelling with you who are under 18 years old (one per line):

PLEASE ANSWER THE FOLLOWING QUESTIONS

1. Within the last 14 days have you, or has any person listed above, presented sudden onset of symptoms of fever or cough or difficulty in breathing?
YESNO

2. Within the last 14 days Have you, or has any person listed above, had close contact with anyone diagnosed as having coronavirus COVID-19?
YESNO

3. Within the last 14 days have you, or has any person listed above, provided care for someone with COVID-19 or worked with a health care worker infected with COVID-19?
YESNO

4. Within the last 14 days have you, or has any person listed above, visited or stayed in close proximity to anyone with COVID-19?
YESNO

5. Within the last 14 days have you, or has any person listed above, worked in close proximity to or shared the same room/environment with someone with COVID-19?
YESNO

6. Within the last 14 days have you, or has any person listed above, travelled with a patient with COVID-19 in any kind of conveyance?
YESNO

7. Within the last 14 days have you, or has any person listed above, lived in the same household as a patient with COVID-19?
YESNO

Please prove you are human by selecting the Flag.