Ship Pre-Arrival Health Declaration Form

Vessel Information

Name of Ship IMO Number Flag State Port of Departure Port of Arrival Estimated Date and Time of Arrival (ETA) Last 10 Ports Visited

Health Information

Has there been any case of illness or death on board during the voyage? Yes No If yes, please provide details Have any health measures (isolation, disinfection, etc.) been taken? Yes No If yes, please specify

Crew and Passengers List

Name	Rank/Position	Gender	Date of Birth	Nationality	Health Status

Declaration

Name of Person Completing Form Rank/Position Date Signature