Maritime Health Declaration Form
Name of Ship
IMO Number
Flag State
Port of Arrival
Arrival Date
Arrival Time
Last Port of Call
Number of Crew
Number of Passengers
Are there any ill persons on board?
Yes
No
If yes, provide details
Have there been any cases of fever, cough, respiratory or gastrointestinal symptoms on board during the voyage?
Yes
No
If yes, provide details
Have any medical interventions taken place during voyage?
Yes
No
If yes, provide details
Any deaths on board during voyage?
Yes
No
If yes, provide details
Additional Information
Name of Master
Signature
Date