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    NKOM Self Declaration Form Rev-07

    Uploaded by

    Adrian Cantaragiu
    This self-declaration form requests visitors to provide information to help ensure safety during the COVID-19 pandemic. Section 1 asks for name and contact details. Section 2 poses yes/no health screening questions about recent travel, symptoms, and potential exposure. Answers will aid in contact tracing if needed. The form must be emailed before arrival and brought for validation at the security gate.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    NKOM Self Declaration Form Rev-07

    Uploaded by

    Adrian Cantaragiu
    134 views1 page
    This self-declaration form requests visitors to provide information to help ensure safety during the COVID-19 pandemic. Section 1 asks for name and contact details. Section 2 poses yes/no health screening questions about recent travel, symptoms, and potential exposure. Answers will aid in contact tracing if needed. The form must be emailed before arrival and brought for validation at the security gate.

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    form to access nkom

    Original Title

    NKOM Self Declaration Form rev-07

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    This self-declaration form requests visitors to provide information to help ensure safety during the COVID-19 pandemic. Section 1 asks for name and contact details. Section 2 poses yes/no health screening questions about recent travel, symptoms, and potential exposure. Answers will aid in contact tracing if needed. The form must be emailed before arrival and brought for validation at the security gate.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    134 views1 page

    NKOM Self Declaration Form Rev-07

    Uploaded by

    Adrian Cantaragiu
    This self-declaration form requests visitors to provide information to help ensure safety during the COVID-19 pandemic. Section 1 asks for name and contact details. Section 2 poses yes/no health screening questions about recent travel, symptoms, and potential exposure. Answers will aid in contact tracing if needed. The form must be emailed before arrival and brought for validation at the security gate.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 1

    Self-Declaration Form

    Dear Visitor,

    Given the evolving situation in COVID-19, we are taking the necessary measures to ensure the safety and well-being of
    our visitors, staff and their families. As such, we request that you take a couple of minutes to fill in this form. The
    information gathered will be useful for contact tracing, should the need arise.

    Section 1: Personnel Information


    Details

    1. Name & Organisation

    2. Email

    3. Name of N-KOM Staff-in-charge of your visit

    Section 2: Questions for Visitors, Contractors, Service Engineer, Client and Vendor
    Questions Y/N Details

    4. Have you visited other infected countries within the last 2 weeks? Have you been
    quarantine or Isolated for 7 days?

    5. Please declare countries travelled during the last one month ( if vessel, last Port
    Call and it’s activity) and date of last crew change?

    6. Do you or any of your family members or roommates have flu-like symptoms


    (e.g. fever, cough etc.)?

    7. Have you had any close contact with anyone who has recently travelled to
    Wuhan or Hubei Province, China and other affected countries?

    8. Do any of your close contacts have flu-like symptoms or COVID19 positive case?

    9. Do you have any housemate/roommate in your accommodation? If yes, is


    he/she under home isolation or home quarantine due to COVID19?

    10. Do you have any reported cases of coronavirus from your Residence or Camp
    and when? Are you one of the close contacts?

    11. Do you have one of these symptoms fever, colds, cough, throat pain, body
    weakness, loose motion now?

    12. Did you attend a COVID-19 Swab Test and When? If Yes, was it for a purpose of
    Offshore activity, Close Contact or Suspected Case? And share the result

    Note: A scanned copy of this form shall be sent to HSSE Health representative prior to departure – minajoy.r@nkom.com.qa, and the visitor or personnel shall bring the original form
    and shall be validated at the Security Gate No 6.

    -------------------------------

    Signature/ Date

    Page 1 of 1

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