IP Address :
Name of ship or inland navigation vessel Registration / IMO No
Arriving from Sailing to
(Nationality)/(Flag of vessel) Master's name
Gross tonnage (ship) Tonnage (inland navigation vessel)
Valid Sanitation Control Exemption / Control Certificate carried on board?
Issued at Date
Re-inspection required ?
Has ship/vessel visited an affected area identified by the World Health Organization ?
Port of visit Port of date
List ports of call from commencement of voyage with dates of depature, or within past thirty days, whichever is shorter
Upon request of the competent authority at the port of arrival, list crew members, passengers or other persons who have joined sip / vessel since international voyage began or within past thirty days, whichever is shorter, including all ports / countries visited in this period (add additional names to the attached schedule) :
Name joined from(1) (2) (3)
Name joined from(2) (2) (3)
Name joined from(3) (2) (3)
Number of crew members on board
Number of passengers on board
If any person died on board during the voyage otherwise than as a result of accident ?
Total no.of deaths
Is there on board or has there been during the international voyage any case of dissease 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 pactitioner consulted ?
If you aware of any condition on board which may lead to infection or spread of disease ?
If any sanitary measure (e.g. guarantine, isolation, disinfection or decontamination) been applied on board ?
if yes, specify type, place and date
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 ?
In the absence of a surgeon, the master should regard the following symptoms as grounds for suspecting the existence of an infectius nature:
(a) fever, persisting for several days or accompanled by (i) prostration; (ii) decreased censciousness; (iii) glandular swelling; (iv) jaundice; (v) cough or shortness of breath (vi) unusual bleeding; (vii) paralysis.
(b) with or without fever: (i) any acute skin rash or eruption; (ii) severe vomiting (other than seasickness); (iii) severe diarrhea; or (iv) recurrent convuisions.
I hereby declare that the particulars and answers to the questions given in this Declarations or Healt (including the Schedule) are true and correct to the best of my knowledge and belief.
To be completed and submitted to the competent authorities by the masters of ships arriving from foreign ports.
Submitted at the port of
Submitted at the date
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