Pre Trip Covid Self Certification Form - Standalone

Pre-Trip COVID-19 Self-Certification Form

Please note: This is a non-submittable sample form.

Please complete this form using the specific link within your student portal.

1You & Your Trip

2General Health

3Vaccination Info

4COVID Test Results

5Submit

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Submitted Vaccination Info
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Vaccination Card Submitted
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program type
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Medical ID
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Enrollment ID
COVID Risk Mitigation Self Certification Form

This form is to be submitted no earlier than the day before travel to the program.

Since the group’s health and well-being in part relies on each participant arriving in good health, we require that each participant complete and submit the following form the day before their program begins.
Depending on your trip and the information you have already submitted to us, we may ask you to upload copies of the following documents.

Vaccination Card - Scanned Copy

COVID-19 Test Result - Scanned Copy
Student Information
First Name*
Last Name*
Email*
Will you be under the age of 18 at any point during the trip?*
Parent/Guardian Information
First Name*
Last Name*
Email*
Trip Information
Where is your trip scheduled to start?*
Which Sea|mester vessel are you joining?*
Does your program start within 24hrs of now? (the time at which you are completing this form)*
This form can only be completed within 24hrs of start time of your program.

Health Questions

Body Temperature
COVID-19 Like Symptoms
Over the past 10 days, have you experienced any symptom that may be associated with COVID-19, such as an elevated body temperature of 100.4 degrees and above, dry cough, loss of taste or smell, etc*
Please give us all of the details of these symptoms (types and dates) and what actions you took.*

Appropriate Personal Health Decision Making
We required all students to consider the 10 days leading up to the program as a “precautionary period” where participants select to operate in an environment of enhanced risk mitigation. This includes limiting exposure by selecting to follow enhanced mitigation practices that may no longer be mandated in their home location (masks, social distancing, avoiding large crowds). We define “limiting exposure” as avoiding unnecessary contact with those who are not operating within an environment of active COVID-19 risk mitigation. Have you followed these guidelines to limit your risk, and the risk to others over the past 10 days?*

Knowledge of Possible Exposure
Have you been in close physical contact with anyone who has tested positive for COVID-19 within 14 days of your trip's start date?*
Please give us all of the details of this interaction and the steps you have taken to ensure that you are not currently infected.*

COVID-19 Vaccination
We require all students to be fully vaccinated* for COVID-19 before the voyage start date. This is the information you have previously submitted to us. Please check it, and If you find errors, edit the information and resubmit it to us.
COVID-19 vaccine you initially received*
Date of your initial vaccination*
MM slash DD slash YYYY

mm/dd/yyy
The date that you received your second dose of vaccine (if applicable)
MM slash DD slash YYYY

mm/dd/yyy
Date of Most Recent Booster (if applicable)?
MM slash DD slash YYYY

mm/dd/yyy
Have you ever tested positive for COVID-19?
Please enter your approximate recovery date*
MM slash DD slash YYYY

mm/dd/yyy

Vaccination Card Upload*
Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.
Our records indicate that we do not have a copy of your vaccination card on file. Please upload one single document of a scanned copy of your official COVID-19 vaccination card. This document must be of good quality and include all pages/sides of your card. File type can be jpg, gif, png, pdf and the max size is 5MB

1. Lab Approved COVID-19 Rapid Antigen Test Result - taken within 48hrs of your expected arrival time on program
Have you taken a lab-certified Rapid Antigen COVID-19 test within 48hrs of arriving aboard the vessel, and have proof of a negative result?*
Please note that “48hrs of arrival to the vessel” is defined as 48hrs from the time that a student is scheduled to arrive aboard the vessel. If there are flight delays or cancellations, students will be required to test again. To be accepted, test results must clearly show the following:
- Laboratory name and contact details
- Student’s name
- Test type taken (Rapid Antigen / PCR etc.)
- Date and time that the sample was taken
- Negative result for Covid-19 or SARS-CoV-2
This is a requirement to join our program and board the vessel. Do not travel to the embarkation point. Please contact us on +1.941-924-6789.
Negative Covid-19 Test Upload*
Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 30 MB.
Please scan/photograph and upload a digital copy of your negative test result. The details outlined above must be clearly visible and fall within the time frame specified. You must carry the original with you for verification. (30mb Max file size)

8. PPE Supplies
Please make certain that you are bringing the following PPE with you for use while traveling to and from the program:

Four (4) N95 or KN95 disposable masks for travel days (use the absolute best while on the plane)

Two (2) quality washable cloth face masks for everyday use ashore

One (1) 3.4oz "travel size" bottle of hand sanitizer

Do you have the above items ready to go?*

Declaration

My signature below indicates that I have answered all of the questions completely and truthfully in the knowledge that minimizing the possibility of importing an active infection into the program is a primary risk management strategy.
Student Signature*
Parent Signature*

Comments
This field is for validation purposes and should be left unchanged.

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Pre-Trip COVID-19 Self-Certification Form

Pre-Trip COVID-19 Self-Certification Form

Please note: This is a non-submittable sample form.

Please complete this form using the specific link within your student portal.

COVID Risk Mitigation Self Certification Form

Student Information

Parent/Guardian Information

Trip Information

Health Questions

Body Temperature

COVID-19 Like Symptoms

Appropriate Personal Health Decision Making

Knowledge of Possible Exposure

COVID-19 Vaccination

1. Lab Approved COVID-19 Rapid Antigen Test Result - taken within 48hrs of your expected arrival time on program

8. PPE Supplies

Declaration

Title