Ship-to-Port Communicable Disease Report
Ship Information
Ship Name
IMO Number
Call Sign
Flag State
Port of Departure
Date of Departure
Next Port of Call
Estimated Time of Arrival
Health Information
Number of Persons on Board
Total Number of Ill Persons
Number of Medical Staff On Board
Description of Cases / Symptoms
Case Details
Name/ID
Age
Sex
Nationality
Position/Rank
Symptoms
Date of Onset
Isolation (Yes/No)
Actions Taken
Medical Treatments/Actions Taken
Reporter Information
Name
Title/Rank
Date