Operating Company

Name:
Address:
Email:
Telephone:

Local Agent

Name:	Arnold Malabre & Co Ltd Bunker One Jamaica Ltd Carib Star Shipping Ltd CMA CGM Jamaica Eagle Agency Logistics Ltd Gateway Shipping International Shipping Ltd International Shipping Ltd Jamaica Freight & Shipping Co. Ltd Lannaman and Morris Ltd Maritima Del Este S.A Ltd Maritime and Transport Services Ltd Maritime Solutions Jamaica Ltd Noranda Bauxite Perez Y Cia R.S. Gamble Transocean Shipping Ltd
Address:
Email:
Telephone:

Seafarer Details

Name:
Seafarer Number:
Passport Number:
Date of Birth:
Onboard Rank:
Country of Issue:
Telephone:
Email Address:
Have you been provided appropriate PPE for the travel?	Yes No
Transit Option:	Join a Vessel Leaving a Vessel
Are you the holder of any other Seafarer identity document?	Yes No

Health Questions

Has a company Pre-departure medical/Health Check been conducted for COVID-19?	Yes No
Has the seafarer tested positive for the antibodies for COVID-19?	Yes No
Does the seafarer have any COVID-19 symptoms or is unwell?	Yes No
Has the seafarer been in contact with anyone testing positive to COVID-19?	Yes No
Details of contact with COVID-19 positive individual (date/location):
Has twice daily temperature testing been conducted for the last 14 days and temperature been normal? (Normal temperature is considered to be less than 37.6oC)	Yes No

Travel Arrangements

Please provide us with your travel arrangement details.

! Date of Travel		! Departure Location
Transportation Phase		! Arrival Location
Transportation Method		Transportation Number
Accommodation Details		Self Isolation/PPE Requirements

Has the seafarer visited any other countries in the last 30 days?:

Yes No

Shipboard Information

Confirm the ship has implemented self-isolation protocols for joining seafarers - including non-essential personnel not to fill bridge berthing/departure duties?	Yes No
Confirm Master has been advised of requirements to disinfect joining/leaving seafarers baggage and clothes following/prior to travel?	Yes No
Confirm Master has been advised that for 14-days after crew-change if any persons onboard exhibit high temperature or COVID-19 like symptoms they are to immediately notify last Jamaican agent to alert Ministry of Health and Wellness (888-754-7792) to allow commencement of contact tracing	Yes No

Lodging Agent

Are you, the seafarer, leaving Jamaica?	Yes No N/A
Has the Maritime Authority of Jamaica agreed to a crew change?	Yes No N/A
Please provide any additional measures stipulated or if crew change refused outline reasons:
Is the terminal notified?	Yes No N/A
Please provide any additional measures stipulated or if crew change refused outline reasons:

Declaration

I

(Name)

of

(Agency)

advise that the information provided in this form is to the best of my knowledge correct and the crew member to whom this form relates has consented that the personal information it contains is being collected in connection with the risks presented by COVID-19, and may be passed onto appropriate stakeholders, health professionals & Commonwealth, State and local officials for the purpose of facilitating a crew change.

Seafarer Documents

Please upload the documents marked as required (!).

Crew Health Self-Declaration and Daily Temperature Records: ( ! )
Seafarer's Employment Agreement (Signed and Dated): ( ! )
Certificate of Competency/Proficiency: ( ! )
Copy of COVID-19 management plan/staff procedures:
COVID Test Result:
Masters Declaration:
Travel Itinerary: ( ! )