MARITIME DECLARATION OF
HEALTH
No_.
To be completed and submitted to thecompetent authorities by the masters of ships
arriving from foreign ports :
Name of ports Date Anchored Time
Name of ship's From To
Nationality Gross Tonnage Net Tonnage
Master's name IMO No./ Registry
No Port of Registry
Sanitation Control Exemption/ Certificate Issued at
Control Certificate Date Re-inspection Yes No
Visit an affected area identified by Yes Port Number of crew
the WHO No Date Number of passengers
List ports of call from commencement of voyage with dates of departure, or within past thirty days, which ever is shorter
including all ports/ countries visited in this period (additional names to the attached schedule)
Name From (1) (2) (3)
HEALTH QUESTION YES NO
Has any person died on board during the voyage otherwise than as a result of
1
accident ' ( lf yes, state particulars In attached schedule)
Is there on board or has there been during the international voyage any case of disease
2 which you suspect to be of an Infectious nature ?
(If yes, state particulars in attached schedule)
Has the total number ill passengers during the voyage been greater than. normal /
3 expected?
How many person ..........................
4. Is there any ill person on board now ' (If yes, state particulars in attached schedule)
Was a medical practitioner consulted? ( If yes, state particular of medical treatment
5
or advice provided in attached schedule )
6 Are you aware of any condition on board which may lead to infectious or spread of disease?
Has any sanitary measure (e.g. quarantine, isolation, disinfection, or decontamination) been
7 applied on board?
8 Have any stowaways been found on board ? (If yes, where did they join the ship (if known))?
9 Is there a sick animal or pet on board?
I Hereby declare that the particulars and answers to the questions given in this Declaration of
Health ( including the schedule ) are true and correct to the best of my knowledge and belief
Signed ...................................
Date ........................... Master
Countersigned ......................
Ship's Surgeon (if carried)
Note : in the absence of surgeon, the master should regard the following symptoms as grounds for suspecting the
existance of a disease of an Infectious nature
