Health Declaration Statement for Vessels
Vessel Details
Vessel Name
IMO Number
Flag State
Arrival Port
Arrival Date
Crew Information
Total Number of Crew
Total Number of Passengers
Health Status
Have any crew or passengers exhibited symptoms of illness on board?
Yes
No
If yes, provide details:
Ports Visited in Last 30 Days
Remarks
Declaration
Name of Declarant
Rank/Position
Date