DFDS Ferry (Immingham) HEALTH DECLARATION FORM – COVID-19 INTERIM MEASURE
We are collecting personal data of visitors to our properties for the purposes of enabling us
to carry out contact tracing and other response measures, in response to any emergency
that may arise due to 2019novel Coronavirus (COVID19) that may threaten the life, health
or safety of other individuals. The information will be destroyed once there are no business
and legal purposes to keep them.
We have the right to refuse entry to any persons who are unwell, who have been to
locations of public health concern in the past 14 days or who have been in contact with any
person with a confirmed case of the coronavirus.
Contact Information:
Full Name Mobile:
DFDS site to be visited: Scheduled date of arrival:
Please indicate if you are:
DFDS staff Visitor (Company name:
Health Wellbeing and Recent Travel History
1. Have you been in contact with any person who is a confirmed case of COVID19 in
the past 14 days? YES NO
2. Have you been to China, South Korea, Hong Kong, Macau, Japan or Italy in the past
14 days? YES NO
3. Do you currently have a fever or any flu symptoms such as coughing, runny nose or
sore throat? YES NO
Acknowledgement
I have answered all questions to the best of my knowledge. I acknowledge and agree to the
collection, use and disclosure of my personal data, health information and recent travel
history for the purposes set out in this Form.
Signature: Date:
For DFDS use only: I have checked the above declaration and the visitor is clear to visit this site.
Print: Signed: Date:
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