Port Arrival Maritime Health Declaration
Vessel Information
Vessel Name
IMO Number
Flag
Call Sign
Voyage Number
Port of Arrival
Arrival Date & Time
Health Status on Board
Number of crew on board
Number of passengers on board
Are there any ill persons on board?
No
Yes
If yes, give details
Symptoms or diseases reported
Port of Call Information
Last port of call
Ports visited in last 30 days
Declaration
Master of Vessel (Name)
Date
Signature