COVID-19 Questionnaire
The following declaration is to identify potential risks or threats to the safety of persons entering INTEGRATED MARINE work sites during the COVID-19 Pandemic. By completing this form the person named agrees that the information provided is true and correct.
Email *
1. First Name *
2. Last Name *
3. Contact Email *
4. Contact Phone Number *
5. Company Name
6. Name of Vessel you are working on *
7. Location of Vessel you are working on *
8. Date of entry to work site *
MM
/
DD
/
YYYY
9. Date of exit from vessel *
MM
/
DD
/
YYYY
10. Have you traveled outside your region in the past 14 days? *
11. Have you been in contact with someone who has entered the country in the past 14 days?
12. if YES, contact details
13. Do you have a history of contact with anyone with COVID-19 contact? *
14. if YES, Contact details.
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