COVID-19 Health Declaration Form

First Participant's Name

First Name*

Last Name*

First Participant's Date of Birth*

I certify that I am 18 years of age or older

First Participant's Information

Today's date

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR- SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*

Yes

2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*

Yes

3. BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY?*

Yes

4. BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*

Yes

The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for any omissions in disclosing my existing or past health conditions. I also commit to inform Indepth Scuba Pty Ltd about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

I also commit to inform Indepth Scuba Pty Ltd about any symptom that may arrive after having filled in this declaration and/or having come into contact with someone who has tested positive after signing the declaration.

ADDITIONAL DECLARATIONS / COVID-19

I WILL, if asked, wear a protective mask at all times while participating in the diving training / activities arranged by Indepth Scuba Pty Ltd, and will take all reasonable preventive steps that may be recommended by Indepth Scuba Pty Ltd, or any relevant public authority.

I WILL accept and observe all instructions by Indepth Scuba Pty Ltd intended to abide by all existing regulations, required to help prevent the risk of transmission, including having my temperature taken prior to participating in any diving activities.

I ACKNOWLEDGE and ACCEPT that this declaration will be considered as my consent to Indepth Scuba Pty Ltd to retain this declaration and disclose it to any relevant authority or service provider for the purposes of ensuring the safety of any third parties that may come in contact with me prior to, during, and after any diving activity.

PLEASE NOTE

COVID-19 shares many of the same symptoms as other serious viral pneumonias that require a period of convalesce before returning to full activities - a process that can take weeks or months depending on symptom severity (1).

MEDICAL RECOMMENDATIONS (2, 3):

• Divers who have tested positive with COVID-19 but have remained completely asymptomatic, should wait ONE month before resuming diving.
• Divers who have had symptomatic COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted by a diving medicine specialist.
• Divers who have been hospitalised with or because of pulmonary symptoms in relation to COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted or coordinated by a diving medicine specialist, with complete pulmonary function testing (at least FVC, FEV1, PEF25-50-75, RV and FEV1/FVC, and an exercise test with peripheral oxygen saturation measurement) as well as a high resolution CT scanning of the lungs.
• Divers who have been hospitalised with or because of cardiac problems in relation to COVID-19, should wait at least THREE months before applying for fit-to-dive clearance conducted or coordinated by a diving medicine specialist with cardiac evaluation, including echocardiography and exercise test (exercise electrocardiography).

GENERAL RECOMMENDATION

• Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe /Divers Alert Network).

REFERENCES

(1) Return to Diving Post COVID-19 - issued by the Undersea and Hyperbaric Medical Society (UHMS) in the USA.
(2) Diving after COVID-19 pulmonary infection. A position statement of the Belgian Society for Diving and Hyperbaric Medicine (SBMHS-BVOOG).
(3) Recreational and professional diving after the Coronavirus disease (COVID-19) outbreak - Position statement of EUBS & ECHM

VERSION: 22.05.2020

The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them.

The Form has been developed by the DAN Europe Medical Division team, based on information available as of May 2020. The epidemiological situation is constantly evolving.As a result, this document may be subject to changes and updates..

First Participant's Signature*

Type Signature

Draw Signature

Change Font

Accept Signature Clear

Click to Sign

Edit Signature

Second Participant's Name

First Name*

Last Name*

Second Participant's Date of Birth*

Second Participant's Information

Today's date

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR- SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*

Yes

2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*

Yes

3. BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY?*

Yes

4. BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*

Yes

ADDITIONAL DECLARATIONS / COVID-19

PLEASE NOTE

MEDICAL RECOMMENDATIONS (2, 3):

GENERAL RECOMMENDATION

• Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe /Divers Alert Network).

REFERENCES

VERSION: 22.05.2020

The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them.

Third Participant's Name

First Name*

Last Name*

Third Participant's Date of Birth*

Third Participant's Information

Today's date

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR- SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*

Yes

2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*

Yes

3. BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY?*

Yes

4. BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*

Yes

ADDITIONAL DECLARATIONS / COVID-19

PLEASE NOTE

MEDICAL RECOMMENDATIONS (2, 3):

GENERAL RECOMMENDATION

• Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe /Divers Alert Network).

REFERENCES

VERSION: 22.05.2020

The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them.

Fourth Participant's Name

First Name*

Last Name*

Fourth Participant's Date of Birth*

Fourth Participant's Information

Today's date

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR- SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*

Yes

2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*

Yes

3. BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY?*

Yes

4. BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*

Yes

ADDITIONAL DECLARATIONS / COVID-19

PLEASE NOTE

MEDICAL RECOMMENDATIONS (2, 3):

GENERAL RECOMMENDATION

• Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe /Divers Alert Network).

REFERENCES

VERSION: 22.05.2020

The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them.

Fifth Participant's Name

First Name*

Last Name*

Fifth Participant's Date of Birth*

Fifth Participant's Information

Today's date

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR- SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*

Yes

2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*

Yes

3. BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY?*

Yes

4. BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*

Yes

ADDITIONAL DECLARATIONS / COVID-19

PLEASE NOTE

MEDICAL RECOMMENDATIONS (2, 3):

GENERAL RECOMMENDATION

• Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe /Divers Alert Network).

REFERENCES

VERSION: 22.05.2020

The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them.

Sixth Participant's Name

First Name*

Last Name*

Sixth Participant's Date of Birth*

Sixth Participant's Information

Today's date

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR- SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*

Yes

2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*

Yes

3. BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY?*

Yes

4. BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*

Yes

ADDITIONAL DECLARATIONS / COVID-19

PLEASE NOTE

MEDICAL RECOMMENDATIONS (2, 3):

GENERAL RECOMMENDATION

• Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe /Divers Alert Network).

REFERENCES

VERSION: 22.05.2020

The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them.

Seventh Participant's Name

First Name*

Last Name*

Seventh Participant's Date of Birth*

Seventh Participant's Information

Today's date

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR- SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*

Yes

2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*

Yes

3. BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY?*

Yes

4. BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*

Yes

ADDITIONAL DECLARATIONS / COVID-19

PLEASE NOTE

MEDICAL RECOMMENDATIONS (2, 3):

GENERAL RECOMMENDATION

• Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe /Divers Alert Network).

REFERENCES

VERSION: 22.05.2020

The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them.

Eighth Participant's Name

First Name*

Last Name*

Eighth Participant's Date of Birth*

Eighth Participant's Information

Today's date

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR- SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*

Yes

2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*

Yes

3. BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY?*

Yes

4. BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*

Yes

ADDITIONAL DECLARATIONS / COVID-19

PLEASE NOTE

MEDICAL RECOMMENDATIONS (2, 3):

GENERAL RECOMMENDATION

• Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe /Divers Alert Network).

REFERENCES

VERSION: 22.05.2020

The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them.

Ninth Participant's Name

First Name*

Last Name*

Ninth Participant's Date of Birth*

Ninth Participant's Information

Today's date

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR- SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*

Yes

2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*

Yes

3. BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY?*

Yes

4. BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*

Yes

ADDITIONAL DECLARATIONS / COVID-19

PLEASE NOTE

MEDICAL RECOMMENDATIONS (2, 3):

GENERAL RECOMMENDATION

• Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe /Divers Alert Network).

REFERENCES

VERSION: 22.05.2020

The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them.

Tenth Participant's Name

First Name*

Last Name*

Tenth Participant's Date of Birth*

Tenth Participant's Information

Today's date

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR- SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*

Yes

2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*

Yes

3. BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY?*

Yes

4. BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*

Yes

ADDITIONAL DECLARATIONS / COVID-19

PLEASE NOTE

MEDICAL RECOMMENDATIONS (2, 3):

GENERAL RECOMMENDATION

• Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe /Divers Alert Network).

REFERENCES

VERSION: 22.05.2020

The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them.

Parent or Guardian's Email Address

Email*

Confirm Email*

Check to receive information, news, and discounts by e-mail.

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.

Parent or Guardian's Name

First Name*

Last Name*

Parent or Guardian's Date of Birth*

I certify that I am 18 years of age or older

Parent or Guardian's Information

Today's date

1. TESTED POSITIVE OR PRESUMPTIVELY POSITIVE WITH COVID-19 (THE NEW CORONAVIRUS OR- SARS-COV2) OR BEEN IDENTIFIED AS A POTENTIAL CARRIER OF THE CORONAVIRUS?*

Yes

2. EXPERIENCED ANY SYMPTOMS COMMONLY ASSOCIATED WITH COVID-19 (FEVER; COUGH; FATIGUE OR MUSCLE PAIN; DIFFICULTY BREATHING; SORE THROAT; LUNG INFECTIONS; HEADACHE; LOSS OF TASTE; OR DIARRHEA)?*

Yes

3. BEEN IN ANY LOCATION/SITE DECLARED AS HAZARDOUS WITH AND/OR POTENTIALLY INFECTIVE WITH THE NEW CORONAVIRUS BY A RECOGNISED HEALTH OR REGULATORY AUTHORITY?*

Yes

4. BEEN IN DIRECT CONTACT WITH OR IN THE IMMEDIATE VICINITY OF ANY PERSON WHO TESTED POSITIVE WITH THE NEW CORONAVIRUS OR WHO WAS DIAGNOSED AS POSSIBLY BEING INFECTED BY THE NEW CORONAVIRUS?*

Yes

ADDITIONAL DECLARATIONS / COVID-19

PLEASE NOTE

MEDICAL RECOMMENDATIONS (2, 3):

GENERAL RECOMMENDATION

• Divers and dive centers should observe strictly the guidelines for disinfection of diving gear (as issued by the diving federations and DAN Europe /Divers Alert Network).

REFERENCES

VERSION: 22.05.2020

The present is a sample of a Health Declaration Form that a dive centre or dive professional may want to adopt and submit to customers and students, before taking up any diving activity with them.

Parent or Guardian's Signature*

Type Signature

Draw Signature

Change Font

Accept Signature Clear

Click to Sign

Edit Signature

Electronic Signature Consent*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

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