SEACOR VESSEL AUCTION INFORMATION

Health Screening Questionnaire - Novel Coronavirus (Covid-19)

Employee / Visitor Information

Date:

Name of Company:

Full Name: Date of Birth:

Age:

Gender: M: F:

Nationality:

Mobile No.:

Please tick as applicable

YES NO

1. Please list any country you have travelled to/from (and/or transit through) in the last 28 days: 2. Do you have any of the following symptoms A. Fever B. Cough C. Headache D. Sore Throat E. Shortness of Breath F. Nausea/Vomiting/Diarrhea G. Any other symptoms (Please Specify): 3. If YES, for any of the symptoms listed in item no. 2 did you visit any health care

facility in the last 28 days? Name & Location of Facility:

Date of Visit:

Any swab (throat or nasal) sample collected during the health screening?

Declaration I hereby declare that the above provided information is true and to the best of my knowledge. I acknowledge and agree to the collection, use and disclosure of my personal data, above health information and recent travel history for the purposes set out in this form. Signature of the Employee / Visitor:

Seacor Marine Use Only

Location: Additional Actions / Recommendations (if any) :

COVID-19 RESET

HEALTH SCREENING QUESTIONNAIRE