Maritime Declaration of Health

Maritime Declaration of Health
To be completed and submitted to the competent authorities by the masters of ships arriving from foreign ports.
Submitted at the port of:
Date:
Name of ship or inland navigation vessel:
Registration/IMO No.
Arriving from:
Sailing to:
(Nationality) (Flag of vessel):
Masters name:
Gross tonnage (ship):
Tonnage (inland navigation vessel):
Valid Sanitation Control Exemption/Control Certificate carried on board?

Issued at:
Yes
No
Yes
No
Yes
No
Date:
Reinspection required?
Has ship/vessel visited an affected area identified by the World Health Organization?
Port:
Date of visit:
List of ports of call from commencement of voyage with dates of departure, or within past 30 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 ship/vessel since international voyage began or within past 30 days, whichever is
shorter, including all ports/countries visited in this period (add additional names to the attached schedule):
(1)
Name:
joined from: (1)
(2)
(3)
(2)
Name:
joined from: (1)
(2)
(3)
(3)
Name:
joined from: (1)
(2)
(3)
Number of crew members on board:
Number of passengers on board:
HEALTH QUESTIONS
Yes
No
1. Has any person died on board during the voyage otherwise than as a result of accident?
If yes, state particulars in attached schedule.
Total number of deaths:
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?
3. Has the total number of ill passengers during the voyage been greater than normal/expected?
How many ill persons:
4. Is there any ill person on board now?
5. Was a medical practitioner consulted?
If yes, state particulars of medical treatment or advice provided in attached schedule.
6. Are you aware of any condition on board which may lead to infection or spread of disease?
7. Has any sanitary measure (eg, quarantine, isolation, disinfection or decontamination) been applied
on board?
If yes, specify type, place and date:
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?
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 bleeding; or (vii) paralysis
(b) with or without fever: (i) any acute skin rash or eruption; (ii) severe vomiting (other than sea sickness); (iii) severe diarrhoea; or
(iv) recurrent convulsions.
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
Countersigned
Master
Ships Surgeon (if carried)
Date:
The following list includes diseases, particulars of which must be entered in the Schedule:
Acute gastroenteritis
Gonorrhoeal infection
Malaria
Salmonellosis
Acquired Immunodeficiency Syndrome

Anthrax
Haemophilus influenzae b
Hepatitis (viral) not otherwise specified
Measles
Meningoencephalitis primary amoebic
Severe Acute Respiratory

Syndrome
Arboviral diseases
Hepatitis A
Mumps
Brucellosis
Hepatitis B
Shigellosis
Syphilis
Campylobacteriosis
Hepatitis C
Neisseria meningitidis invasive

diseases
Tetanus
Creutzfeldt Jakob Disease and other

spongiform encephalopathies
Highly Pathogenic Avian Influenza

(including HPAI subtype H5N1)
Pertussis
Chancroid
Hydatid disease
Poliomyelitis
Cholera
Cryptosporidiosis
Legionellosis
Leprosy
Rabies
Rheumatic fever
Diphtheria
Leptospirosis
Rickettsial diseases
Viral haemorrhagic fevers

Yellow fever
Giardiasis
Listeriosis
Rubella
Yersiniosis
Tuberculosis
Plague
Typhoid and paratyphoid

fever
Venereal granuloma
Cases of tuberculosis are notifiable under the Tuberculosis Act 1948 and cases of venereal diseases are notifiable under the Venereal Diseases
Regulations 1982.
Attachment to Maritime Declaration of Health

Name
Class or
rating
Age
Sex
Nationality
Port, date
joined ship/
vessel
Nature of illness
Date of
Reported to a
onset of
port medical
symptoms officer?
Disposal
of case*
Drugs, medicines
or other treatment
given to patient
* State: (1) whether the person recovered, is still ill or died; and (2) whether the person is still on board, was evacuated (including the name of the port or airport), or was buried at sea.
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Maritime Declaration of Health

Submitted at the port of:

Name of ship or inland navigation vessel:

(Nationality) (Flag of vessel):

Gross tonnage (ship):

Tonnage (inland navigation vessel):

Valid Sanitation Control Exemption/Control Certificate carried on board?

joined from: (1)

joined from: (1)

joined from: (1)

Number of crew members on board:

Number of passengers on board:

Ships Surgeon (if carried)

Acquired Immunodeficiency Syndrome

Severe Acute Respiratory

Neisseria meningitidis invasive

Creutzfeldt Jakob Disease and other

Highly Pathogenic Avian Influenza

Viral haemorrhagic fevers

Typhoid and paratyphoid

Attachment to Maritime Declaration of Health

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