Port Health Declaration
Vessel Information
Vessel Name
IMO Number
Flag State
Call Sign
Gross Tonnage
Port & Voyage
Port of Arrival
Date of Arrival
Last Port of Call
Next Port of Call
Crew & Passengers
Number of Crew
Number of Passengers
Medical Declaration
Persons ill/sick on board
Details of illness/cases, including action taken
Declaration by Master
Name of Master
Date
Signature