Pre-Arrival Maritime Health Declaration Form
Vessel Information
Vessel Name
IMO Number
Flag
Call Sign
Arrival Port
Estimated Date of Arrival
Name of Master
Last Port of Call
Health Information
Total Number of Crew
Total Number of Passengers
Number of ill persons on board
Describe symptoms and nature of illness (if any)
Details of any medical assistance provided
Details of any case(s) of death, disease or disposal of body(ies) during the voyage
Additional relevant information
Declaration
I declare that the above statement and information are true and correct to the best of my knowledge and belief.
Name
Position
Date
Signature