MARITIME DECLARATION OF HEALTH

Note : Please consult "Fields description" sheet before filling the fields.

Yes Issued at: AUBUY

Valid Sanitation Control Exemption/ Control (IDENTIFIED BY ITS 5-DIGIT LOCODE)
Certificate carried on board?
(SELECT ONLY VALUES FROM THE LIST: YES/NO)

Re-inspection required? No
(SELECT ONLY VALUES FROM THE LIST: YES/NO)

Has the ship/vessel visited an affected area identified by the World Health No
Organization?
(SELECT ONLY VALUES FROM THE LIST: YES/NO)

Port visited Date

Accepted formats: [DD/MM/YYYY],
(IDENTIFIED BY ITS 5-DIGIT LOCODE) [DD.MM.YYYY]

Health questions

(1) Has any person died on board during the voyage otherwise than as a result of accident? If yes, state particulars in No
schedule below.
(SELECT ONLY VALUES FROM THE LIST: YES/NO)
 (1) Has any person died on board during the voyage otherwise than as a result of accident? If yes, state particulars in
schedule below.
(SELECT ONLY VALUES FROM THE LIST: YES/NO)

No
(2) Is there on board or has there been during the international voyage any case of disease which you suspect to be of an
infectious nature?
If yes, state particulars in schedule below.
(SELECT ONLY VALUES FROM THE LIST: YES/NO)

No
(3) Has the total number of ill passengers during the voyage been greater than normal/expected?
(SELECT ONLY VALUES FROM THE LIST: YES/NO)

(4) Is there any ill person on board now? No

If yes, state particulars in schedule below.
(SELECT ONLY VALUES FROM THE LIST: YES/NO)

(5) Was a medical practitioner consulted? If yes, state particulars of medical treatment or advice provided in schedule No
below.
(SELECT ONLY VALUES FROM THE LIST: YES/NO)

(6) Are you aware of any condition on board which may lead to infection or spread of disease? If yes, state particulars in No
schedule below.
(SELECT ONLY VALUES FROM THE LIST: YES/NO)

No
(7) Has any sanitary measure (e.g. quarantine, isolation, disinfection or decontamination) been applied on board?
(SELECT ONLY VALUES FROM THE LIST: YES/NO)

Date
Accepted formats: [DD/MM/YYYY], Place Type
[DD.MM.YYYY]

.
(8) Have any stowaways been found on board? * No
(SELECT ONLY VALUES FROM THE LIST: YES/NO)
(8) Have any stowaways been found on board? *
(SELECT ONLY VALUES FROM THE LIST: YES/NO)

(9) Is there a sick animal or pet on board? No

(SELECT ONLY VALUES FROM THE LIST: YES/NO)

Note: In the absence of a surgeon, the master should regard the following symptoms as grounds for suspecting the existence of a disease of an infectious nature:
(a) fever, persisting for several days or accompanied by (i) prostration; (ii) decreased consciousness; (iii) glandular swelling; (iv) jaundice; (v) cough or shortness of breath; (vi) unusual b
(b) with or without fever: (i) any acute skin rash or eruption; (ii) severe vomiting (other than sea sickness); (iii) severediarrhoea; or (iv) recurrent convulsions.

Health - MDH Attachment

Crew or passenger * Crew/Passenger number * Sex Date joined ship
Nr (SELECT ONLY VALUES FROM THE LIST: (MUST MATCH THE CREW/PASSENGER (SELECT ONLY VALUES FROM THE LIST: Accepted formats:
CREW/PASSENGER) NUMBER FROM CREW/PASSENGER LIST) MALE/FEMALE) [DD/MM/YYYY],
[DD.MM.YYYY]
Date:
Accepted formats: [DD/MM/YYYY 15.10.2018 14:00
HH:mm], [DD.MM.YYYY HH:mm]

Total no. of deaths:

How many ill persons?

If yes, where did they join

the ship (if known)?
 If yes, where did they join
the ship (if known)?

of an infectious nature:
(v) cough or shortness of breath; (vi) unusual bleeding; or (vii) paralysis.
urrent convulsions.

Date of onset of symptons Reported to a port medical officer?

Nature of illness Accepted formats: (SELECT ONLY VALUES FROM THE LIST: State Disposal of case
[DD/MM/YYYY], [DD.MM.YYYY] YES/NO)
Location of evacuation Treatment Comments
 Informations about filling the fi

Section name Subsection name Field name

Health

Valid Sanitation Control

Exemption or Control Certificate
carried on board

Issued at

Date of issue

Re-inspection required

Has the ship/vessel visited an

affected area identified by the World
Health Organization?

Port visited
 Date

Health questions

Has any person died on board

during the voyage otherwise
than as a result of accident?

Total number of deaths

Is there on board or has there been

during the international voyage any
case of disease which you suspect to
be of an infectious nature?

Has the total number of ill

passengers during the voyage
been greater than
normal/expected?

How many ill persons

Is there any ill person on

board now?

Was a medical practitioner

consulted?

Are you aware of any condition

on board which may lead to
infection or spread of disease?
 Has any sanitary measure (e.g.
quarantine, isolation, disinfection or
decontamination) been applied on
board?

Date

Place

Type

Have any stowaways been found

on board?

If yes, where did they join the ship (if

known)?

Is there a sick animal or pet

on board?

Health-MDH
Attachment

Crew or passenger

Crew or passenger number

Sex

Date joined ship

Nature of illness

Date of onset symptons

Reported to a port medical officer

State

Disposal of case

Location of evacuation

Treatment

Comments
ations about filling the fields

Field occurence Field description

Must be provided (only

for exceptional cases, the
Valid Sanitation Control Exemption or Control Certificate carried on
notification can be
board? Possible values: Yes/No.
submitted without
providing this field)

Location where the Sanitation Control Exemption or Control Certificate was

Must be provided (only issued. This field is available only if "Valid Sanitation Control Exemption or
for exceptional cases, the Control Certificate" = Yes.
notification can be The designated port which is identified by its 5-digit LOCODE. This field must
submitted without contain exactly 5 characters which should represent the unique code of the port
providing this field) (example: "ROAGI" for Agigea port).
Two-letter country code as defined in ISO 3166-1 + three-letter location code as
defined in UNECE R16. The location code “XXX” is reserved for an unknown
location code.

Must be provided (only Date when the Sanitation Control Exemption or Control Certificate
for exceptional cases, the was issued. This field is available only if "Valid Sanitation Control Exemption or
notification can be Control Certificate carried on board?" = Yes.
submitted without The date and time must be written in the following format: "[DD/MM/YYYY
providing this field) HH:mm]", "[DD.MM.YYYY HH:mm]" or default date/time format strings, where
"DD" represents the day of month, "MM" represents the month of year, "YYYY"
represents the year, "HH" represents the hour and "mm" represents the
minutes (example: [22/03/2000 10:45]).
Must be provided (only
for exceptional cases, the
notification can be Re-inspection required? Possible values: Yes/No.
submitted without
providing this field)

Must be provided (only

for exceptional cases, the
Indicates if the ship has visited an infected area identified by the
notification can be
World Health Organisation (WHO). Possible values: Yes/No.
submitted without
providing this field)

Must be provided (only The search function shall be used. This field shall be provided only if "Visited
for exceptional cases, the infected area" = Yes.
notification can be The designated port which is identified by its 5-digit LOCODE. This field must
submitted without contain exactly 5 characters which should represent the unique code of the port
providing this field) (example: "ROAGI" for Agigea port).
Two-letter country code as defined in ISO 3166-1 + three-letter location code as
defined in UNECE R16. The location code “XXX” is reserved for an unknown
location code.
 Must be provided (only
for exceptional cases, the This field is available only if "Visited infected area" = Yes.
notification can be The date must be written in the following format: "DD/MM/YYYY",
submitted without "[DD.MM.YYYY]", or default date/time format strings,
providing this field) where "DD" represents the day of month, "MM" represents the
month of year and "YYYY" represents the year (example: [22/03/2000]).

Must be provided (only

for exceptional cases, the
Has any person died on board during the voyage otherwise than as a
notification can be
result of accident? Possible values: Yes/No.
submitted without
providing this field)

Must be provided (only

for exceptional cases, the
This field is available only if "Has any person died on board during the voyage
notification can be
otherwise than as a result of accident?" = Yes.
submitted without
providing this field)

Must be provided (only

for exceptional cases, the Are you aware of any condition on board which may lead
notification can be
to infection or spread of disease? Possible values: Yes/No.
submitted without
providing this field)

Must be provided (only

for exceptional cases, the
Has the total number of ill passengers during the voyage been greater than
notification can be
submitted without normal/expected? Possible values: Yes/No.
providing this field)

Number of ill persons during the voyage. This field is available only if "Has the
Mandatory total number of ill passengers during the voyage been greater than
normal/expected?" = Yes.

Must be provided (only

for exceptional cases, the
notification can be
submitted without
providing this field) Is there any ill person on board now? Possible values: Yes/No.
If selected, the “Health - MDH Attachment” shall be provided.
Must be provided (only
for exceptional cases, the
notification can be If a medical practitioner was consulted. Possible values: Yes/No.
submitted without
providing this field)

Must be provided (only

for exceptional cases, the
notification can be If on board exist any infection conditions. Possible values: Yes/No.
submitted without
providing this field)
 Must be provided (only
for exceptional cases, the
Has any sanitary measure (e.g. quarantine, isolation, disinfection or
notification can be
decontamination) been applied on board? This is a yes/no data element.
submitted without
providing this field)

Shall be filled, if “Has any sanitary measure (been applied on board?” = Yes.
Mandatory The date must be written in the following format: "DD/MM/YYYY",
"[DD.MM.YYYY]", or default date/time format strings,
where "DD" represents the day of month, "MM" represents the
month of year and "YYYY" represents the year (example: [22/03/2000]).

Mandatory Place of sanitary measure. Shall be filled, if “Has any sanitary measure been
applied on board?” = Yes. This field can contain maximum 255 characters.

Type of sanitary measure.

Mandatory Shall be filled, if “Has any sanitary measure been applied on board?” = Yes. This
field can contain maximum 255 characters.
Must be provided (only
for exceptional cases, the
notification can be Have any stowaways been found onboard? Yes/No data element.
submitted without
providing this field)

Location where the stowaways is assumed to have joined

Mandatory the ship, if any. Shall be filled, if “Have any stowaways been found
on board?” = Yes. This field can contain maximum 255 characters.
Must be provided (only
for exceptional cases, the
notification can be Is there a sick animal or pet on board? Yes/No data element.
submitted without
providing this field)

Mandatory Indication if the person is crew or passenger.

Possible values: Crew/Passenger
An unique number for each crew member or passenger, number that will be
Mandatory
taken from the Crew or Passengers list.

Must be provided (only

for exceptional cases, the
notification can be
submitted without
providing this field) The gender of the crew member or the passenger.
Possible values: Male/Female.

Must be provided (only

for exceptional cases, the Date when the person embarked the ship.
notification can be The date must be written in the following format: "DD/MM/YYYY",
submitted without "[DD.MM.YYYY]", or default date/time format strings,
providing this field) where "DD" represents the day of month, "MM" represents the
month of year and "YYYY" represents the year (example: [22/03/2000]).
 Must be provided (only
for exceptional cases, the
notification can be Nature of illness.
submitted without
providing this field)

Must be provided (only

for exceptional cases, the Date of onset of symptoms.
notification can be The date must be written in the following format: "DD/MM/YYYY",
submitted without "[DD.MM.YYYY]", or default date/time format strings,
providing this field) where "DD" represents the day of month, "MM" represents the
month of year and "YYYY" represents the year (example: [22/03/2000]).
Must be provided (only
for exceptional cases, the
notification can be Reported to a port medical officer? Yes/No values.
submitted without
providing this field)

Must be provided (only

for exceptional cases, the
The status of person. Whether the person recovered,
notification can be
is still ill or died. This field can contain maximum 255 characters.
submitted without
providing this field)

Must be provided (only

for exceptional cases, the
Whether the person is still on board, was evacuated, or was buried at sea. This
notification can be
field can contain maximum 255 characters.
submitted without
providing this field)

Must be provided (only

for exceptional cases, the
Name of the port or airport where person was evacuated. This field can contain
notification can be
maximum 255 characters.
submitted without
providing this field)

Must be provided (only

for exceptional cases, the
Drugs, medicines or other treatment given. This field can contain maximum 255
notification can be
characters.
submitted without
providing this field)

Must be provided (only

for exceptional cases, the
Comments on the specific case in the MDH attachment. This field can contain
notification can be
maximum 255 characters.
submitted without
providing this field)
3.2