Maritime Declaration of Health
Name of Ship:
Call Sign:
Voyage Number:
Flag State:
Port of Departure:
Port of Arrival:
Date of Arrival:
Hour of Arrival:
Name of Agent:
Persons on Board
Crew (Number):
Passengers (Number):
Health Questions
Has there been on board during the voyage any case or suspected case of communicable disease?
Yes
No
If yes, specify details:
Has any person died on board during the voyage otherwise than as a result of accident?
Yes
No
If yes, state particulars:
Ports of Call
Port
Date of Arrival
Date of Departure
Additional Information
Details of any sick person(s) on board, health measures taken, or other remarks:
Name of Master:
Date:
Signature: