ANNEX B

The MDH must be compbted and submitted a maximum of 12 hours bebre anival, with an update, if the heatth status of
any one on board changes

N'IARITIME DECLARATION OF HEALTH

Ta he ffirnplsted and submitd ta the sffipet€nt autilnrities by the r&aster$ d ships aniving from foreign po*s.

submind ar rhe port sf .ruqr:tlf {Y'+L+Yf.l*}.. .. Date .Itl.9.?11 3.*3. . ...

Name of ship or inland navigatbn vessel BINTANG LIBERTY 3

aniving frarn.Sll'{.9*I9nF".. seitins to

SINGAPORE

{Ndisndity}{F?as of ve*seg .*Wl1{,Il*9.. Ma*tefs nam6 YAFAO HAREFA

Gross tcnnage {ship} .ltl.q I.".-" :

To*rqe {inland navigation wssd} .9LL.I..

vfrd saritdion contot rlcmfrtutcorfiot certificate canied on rlmz ves ...8I... * ..-fJ.... lo* * .[!:19.t11119. o*e .l]i*.
Reirspeciion rqull*l ves ..fl r,ro ."El
Fllasshiplessd vidted an &dedsE€ klenlified byttelllbdd lladh Orgnnizdica?Yee EIof" E
port a.d da.e d vi$it .llY.c. !1ll!9{l!{Y.i'L l-?.-b..9IIIT.f-.
Ust DortB dcat torn comme!rcen with de(e6 of &padulB, or within pd thtly days, $tdctt€|t/Er is shorter
KtrcHrNG, ErA **r-*o oo #l-SISry

Upon equest cf the @np€&at adtpdty at lhe poil of anivd, list c'q,. rErnbers, p6sengE s or offier per$ns rvho ha\re Fined stip/vessd sime ir{emationd
vofqe begen orridthin pdthirlydayB, v*S{*!ever i€ shorler, indudalts d ports/cour*ries visiled in tt*s pqiod (d
dd'rliond narnesl,oltE attdrd $tledde}

Number d c€rv rnembels oa b€rd .3!.qe$9.r.,.

Number of p&engers on board .l+..."........

Heallhquestions F
{1) }b any person ded on boad durirq the voy{e ottreruise than as a reeult of *lA",nf Vo [Jfo El
f F, dde parti{illars in #dred s<fiedde. Total no. d dedrs .lF-.....
(2) lsttlFllon bqarC orhastherebeen dudngthe inlenHkmd voyagEanycaseofdiseaewhictryou suspedtobe dan infet*ious ndure?
YesI-[. tlo,ll[. f y€6, date parli€ilhrs in dadled 8cfiedd6.
(3) Has lhe totd numbar cf i[ p*serpels dudng lte voyage b€an grcater than mflrldl€reeffi? VoE f.fo H How *rany il
frsors?.mr,.,
(4) ls there ary iS person on boad rprcl Ycs .tr. m El. f ]r€6, stde particulars in dffiied sdrcdule.

t5) vusaflledicdprditionerconsrlted?Yec.fl*oElfty*,statepadicuhsdmeclcdlrcatnterltordvkeprwkledinffidredule.
{6) Are you auas d any coftffion an boad which may bad to inHion or spread a *mea ves -El. * El.
f yes, state perti(I.rhrs in dtdled s.*€dub.
{7) Has any sanitary measure isolation, disinfectian $r decontarnination) been applied on bsard? Yes .fl nf" [1
lf yes, specify type, place

{8) thre ary stsranr4/s been bund on board? Vo p. f.U .H f ,o, rt ur" Oa frey join the ehip gf kmwnP
(9) ls ttlerc a gd( animd or pet on boadt vo ..H. r,f .El.
l,{ole: ln lhe absenG of E surgeon, lhe rnaster stpdd regard the ronou,ing rymdoms as gounds lor srspectiqg tt}e e)ds*ence of a disease of an ir&ious
nature:
(a) fetEr,persistirgfor*A,erddaysorffimp€niedby(0prosfration;E)decr€sedconsiousness;{iti)g&BrdularflEiling;{iv}iaurxfce;(v)
cough or shortness of brcdh; (vi) un*sual bleeding; or (viD pddysis.
(b) qd*t or wi8nrn faer (i) ary ale
skin rdt or eruption; (iD setrsre tor*tirlg {otfier tfran sea sickres); {fi) s€sere danhea; or {iv) rc<rrrreril
convrdsions

I hereby declare that the padiculars and ansu/ers to the questions given in this Declardion of Heallh (induding the schedule) are true and coned to the best of my
knowledge and beliel

Feb 05th 2423

Date Signed......

Countersigned
(if carried)
1
a' TER *
 ATTACHMENT TO MODEL OT MARITIME DECLARATION OF HMALTII

Name Slass or Age $ex Nationality Port and date Nature of illness Date of onset of Reported to a Disposal of case* Drugs Comments
rating joined symptoms poft medical medicines or
ship/vessel officer? other
treatment

NIL

Sfafei
1) Whather tho perwn re@,vercd, ls *iil ill ordied; and
2)Whetherthi porson is sri,/on toat&was evacuated (induding lhe name af tha portar airport), arwasburied at sea.

?
 List of Passengers/ crew Members
with Temperature above 37.50c
Sl Ho. Name Nationality Temperature Remarks
01 NIL NIL

{
IORM A
hlarne of Ship : MV. BIFITANG LIBERTY 3 Lnst Port of Depnrturs r Kuching Date of Departure ! Feb 05th 2023
(Malaysia)
Last Port of Call within the past 14 days

hlarne Gender Rank & Nationality Place of Issue of Passport Countries Temperature
Designation visited for the AM/PM
Iast 14 days
Yafao Harefa M Master IDNI KJRI Kuching,2 5 I 03 12A27 Malaysia 36.2 0C 36.3 0g
Yaredi Halawa M Chief Officer IDNI KJRI Kuching,2 I I 1212A2,6 Malavsia 36.1 0; 36.3 og
Niondrasi Harefa M }nd Officer IDNI Taqiung Priok, 05103 12025 Malaysia 36.2 0C 36.3 0g
Herman Lase M Chief Engineer IDI.t Taqiuns Priok, 16101 12025 Malaysia 36.1 0g 36.4 0C
Wilhelmus Baloni ].{druru M znd trngineer II)N Batam , 2910112026 Malaysia 36"2 0C 36.3 0g
Masa Berkat Lase M 3'd Engineer ID}{ Sibolf;ir, 10i03 12027 Malaysia 36.1 0g 36.3 06
Levisffi&n Zalukhu M Boatswain IDN KJRI Kuchins, 2Il I2nA25 Malaysia 36.1 0g 36.2 0C
Memotani Ziliwu M AB IDNI Te. Priok, 2310A2A26 Malaysia 36.2 0C 36.4 0C
Andreas Alvino A. Kepala M AB IDhI Batam,, L7 10612026 Malaysia 36.1 og 36.2 0C
Alfundi Nitema Zebua M AB IDN Ts.Priok, 2411212A26 Malaysia 36.2 og 36.3 0g
Agus Salim M Oiler IDN KJRI Kuching, 2L I I2l2A25 Malaysia 36.1 ttg 36.3 0g
Yulius Yatona V/aruwu ,M Oiler IDN Taniuns Priuk, 28l}g n023 Malaysia 36.24C 36.3 og
Omarieli Harefa M Oiler ID].{ Sibols&, A4lA4nA27 Malaysia 36.2 og 36.2 0C
Iman Jaya Telaumbanua M Cook IDN KJRI Kuching,3 0 fi9 12024 Malaysia 36.1 og 36,3 0g

BI 3

''',
1
*
rlr
M er

T
FORM A
hlame of Ship : MV. BI1YTANG LIBH,RTY 3 Last Port of Departure : Kuching Date of Departure : Feb 04th 2023
(Mnlaysin)
Last Port of Call within the past 14 days

It{ame Gender Rank & Nationalify Place of Issue of Passport Countries Temperature
Designation visited for the AM/PM
last 14 days
Yafao Harefa M Master IDN KJRI Kuchins,Zsi03 12027 Malaysia 36.20C 36,3 0C
Yaredi Halawa M Chief Officer IDT{ KJRI Kuchins,2 L l 1212026 Malaysia 36.20C 36.4 0C
Niondrasi Harefa M }nd Officer IDNI Taniuns Priok, 0510 3 12025 Malaysia 36.1 o6 36.3 0C
Herman Lase M Chief Ensineer IDN Taniuns Priok, 16101 12025 Malaysia 36.2 0C 36.3 ttg
Wilhelmus B aloni ].{druru M znd Engineer IDN Batam , 2910112026 Malaysia 36.2 0C 36.3 og
Masa Berkat Lase M 3'd Hngins$r IDN Sibolsn, 10/03 12027 Malaysia 36.2 0C 36.3 og
Levisman Zalukhu M Boatswain IDhT KJRI Kuchins, TL|LAZAL| Malaysia 36.3 0g 36,4 0C
Memotani Ziliwu M AB ID}T Tg. Priok,2310212026 Malaysia 36,1 0g 36.2 0C
Andreas Alvino A. Kepaln M AB m].{ Batam,lT 10612026 Malaysia 36"2 0C 36"3 06
Alfandi Nitema Zebua M AB IDN Tg.Priok,24lLZ%A26 Malaysia 36.2 0C 36.2 0C
Asus Salim M Oiler IDN KJRI Kuchins, 2Il 1212025 Malaysia 36,I 0g 36.2 0C
Yulius Yatona Waruwu M Oiler IDN Taniuns Priuk, 281 Ag n023 Malaysia 36,2 0C 36,2 0C
Omarieli Harefa M Oiler IDI.{ Sibolf,&, ANA4%A27 Malaysia 36,1 og 36.20C
Iman Jnya Telaumbanua M Cook IDhI KJRI Kuchins, 30/09 nA24 Malaysia 36.2 0C 36.4 0C

J
,[

rM er