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HR-1005 Annex 4 Self-Declaration COVID-19 Booster

This document is a self-declaration form for crew members of Costa Crociere ships. By signing, crew members declare that they understand Costa Crociere's COVID-19 vaccination requirements based on destination country rules and the assessment of the Company's Competent Doctor. Crew members agree to disclose and keep up to date their COVID vaccination and booster status. They also consent to receiving vaccinations if not already vaccinated/boostered, or risk not being allowed to embark.

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100 views2 pages

HR-1005 Annex 4 Self-Declaration COVID-19 Booster

This document is a self-declaration form for crew members of Costa Crociere ships. By signing, crew members declare that they understand Costa Crociere's COVID-19 vaccination requirements based on destination country rules and the assessment of the Company's Competent Doctor. Crew members agree to disclose and keep up to date their COVID vaccination and booster status. They also consent to receiving vaccinations if not already vaccinated/boostered, or risk not being allowed to embark.

Uploaded by

giovanni
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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SELF DECLARATION

Surname

Name

E-number

Position on board

By signing this declaration, I herewith declare as follows:

1. I am informed that in several destination countries have implemented - or are in process to implement –
as a prerequisite to operate ships the requirement to have all crew members on board fully
vaccinated1/immunised2/boostered3 against Covid-19.

2. I am informed that the Medico Competente (“Competent Doctor”) of the Company, who is in charge of the
surveillance of the health of the Company’s workers, has assessed the risk of COVID-19 contagion on
board as medium-high, and therefore, required the 100% of crew members, or 90% depending on the
working position assigned, to be vaccinated and boostered against Covid-19 to be considered “fit to work”.

3. I acknowledge that the Company has a need to plan the crew member embarkation according to their
vaccination/immunisation status to fulfil the requirements from time to time requested by destination
Countries and/or by the Competent Doctor instructions.

4. Since I am currently either (i) assigned to join one of the vessels of Costa Crociere that is planned to call
destinations as per 1) or I’m already on board one of those vessels and/or (ii) I am assigned to a working
position that requires to follow the Competent Doctor instructions, I accept that Costa Crociere is rightfully
entitled to request and document my COVID vaccination and/or my COVID immunisation status.

5. I acknowledge that if I am not COVID immunised or yet fully vaccinated and boostered with an WHO /
EMA approved vaccine,:
 I give my free consent to receive a vaccination4 including booster by an approved doctor either
 before departure from my home country or
 in one of the ports of destination
 or on board the vessel
by voluntarily adhering to the vaccination campaign organized by Costa Crociere
 If I do not give my consent to receive a vaccination or to reveal details of my existing
vaccination/immunisation/booster status, I am aware that I cannot embark a Costa vessel
6. I acknowledge that the Company for organizational needs, dictated by the prerequisite to identify within a
reasonable period prior to the departure of the vessel the staff that can be embarked, has to know if a
crew is not vaccinated / do not intend to vaccinate / do not want to provide documentation to prove this
status. Therefore, if I find myself in one of the situations described above will be required to
communicate it to the Company by placing a flag in the box below and the employer is rightfully
entitled to stop my embarkation.

 I don’t want to declare/prove my vaccination / immunisation status

_____________________________
Place and date Seafarer

_________________________________________
Surname, Name Signature

1
Fully vaccinated against COVID are those who have received the 2nd vaccine dose, with effect from 1 week after vaccination.
2
Immunised against COVID are those who by approved laboratory method has tested positive for COVID, with a duration from de-
isolation to 3 months after the date of the test.
3
Boostered against COVID are those who have received a 3rd vaccination with a mRNA vaccine after 28 days of the 2nd shot for non EMA
approved vaccine or after 120 days of the 2nd shot for an EMA approved vaccination
4
if you already received vaccination with a non WHO / EMA approved vaccine, consult the Doctor for further advice.
Privacy Notice

1. Controller & Data Protection Officer (DPO)


The data controller is Costa Crociere S.p.A. Piazza Piccapietra 48, Genoa. The DPO may be contacted
via email to privacy@costa.it.
2. Purpose & Legal Basis
The purpose of the processing activity is to adopt the appropriate safety measures for the containment
and prevention of the COVID-19 infection on board of the Costa Crociere’s vessels calling ports where
the Country has imposed or is in the process of implementing a statutory requirement for Covid-19
vaccination/immunisation for the people on board and for organizational measures. The legal basis for
the processing is the national law of the Countries where from time to time the ships are operating and
where are imposed vaccination/immunisation requirements and the Biological Risk Assessment From
Exposure To Sars-Cov-2 drafted by the Competent Doctor as amended and supplemented.
3. Nature of data disclosure
The disclosure of personal data is necessary for the implementation of the national COVID-19
Regulations and for the implementation of the measures adopted by the Company for the containment
and prevention of the spread of COVID-19, as well as to ensure the protection of those who are aboard,
including crew members, in accordance with the provisions regarding the protection of health and safety
in the workplace. Therefore, any refusal to disclose information required shall make boarding impossible
or prevent the Company from adopting, in compliance with the applicable legal provisions, the
necessary safety measures.
4. Recipient Categories
Your personal data shall not be either disclosed or communicated to third parties for purposes other
than those provided for by the specific regulatory provisions (for example, a request by the Health
Authority).
5. Technical and organisational safety measures
In compliance with the principle of data minimisation and as part of the implementation of the national
COVID-19 Regulations and the Competent Doctor assessment and instructions, only the data that are
strictly necessary for the purposes of such regulations shall be collected and they shall be processed
exclusively for the purpose stated above.
Moreover, personal data shall be processed by the Company’s medical personnel as well as, where
necessary, by the Competent Doctor.
6. Deletion
The data submitted will be stored for the duration of your stay on board of a Costa vessel calling ports
where there is the requirement for Covid-19 vaccination/immunisation or for the duration of your working
contract and, in any case, for the retention period provided for by the law.
7. Rights of Data Subjects
As a data subject within the meaning of the GDPR, you may contact us to exercise the following rights
acknowledged by the GDPR:
- Right of access in accordance with Art. 15 GDPR
- Right to rectification in accordance with Art. 16 GDPR
- Right to erasure in accordance with Art. 17 GDPR
- Right to restriction of processing in accordance with Art. 18 GDPR
- Right to object in accordance with Art. 21 GDPR
- Right to lodge a complaint with a supervisory authority in accordance with Art. 77 GDPR
- Right to withdraw your consent in accordance with Art. 7 (3) GDPR.

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