Free Pratique AppIication: Fax Original Message from Master to Port Health.

Cape Town (In the event of OPL for medical attendance, please provide in addition, full detail regarding condition(s) of patient.} a. b. c. d. e. f. g, Name of Vessel Estimatad time of arrival (ETA) Last Ports and departure dates going back 30 days No of crew De-Ratting / De-Ratting Exemption status Vaccination status Health Status of the Crew and Vessel (ZS/ZT)

'" Note: ~ The Health Questions (especially Question 5) of the Maritime Declaration of Health, do not refer to those of Marburg Viral Hemorrhagic Fever. The following symptoms must also be considered when answering this saction: Onset is sudden with fever, myalgia, sore throat and fatigue. Gastrointestinal symptoms are common notably profuse diarrhea, nausea and vomiting and abdominal pain. Maculopapular rash is common, appearing about day 5 of illness. Hemorrhagic manifestations occur from about days 5 -7 of iIIness in 50 % of patients. A poor prognosis is marked by hemorrhagic signs as welt as oliguria, metabolic acidosis, shock and respiratory distress.

h. The following information on crew changes going back 30 days:-Where was crew change effected, name of crew, movement of crew prior to boarding vessel? i. j. Name of local Shipping Agency Vessel's Sal C, Telex, Facsimile Numbers & Call sign