International Maritime Health Declaration (IMHD) Form
Vessel Information
Vessel Name
IMO Number
Flag State
Call Sign
Voyage No.
Arrival Information
Port of Arrival
Departure Port
Arrival Date
Arrival Time
Master's Information
Master's Name
Telephone/Email
Health Declaration
Number of crew on board
Number of passengers on board
Any person(s) ill or showing symptoms?
Yes
No
If yes, provide details below:
Name
Position
Symptoms
Date of onset
Action taken
Recent ports of call (last 30 days):
Any deaths occurred on board? If yes, give details:
Declaration
I hereby declare that the particulars and answers to the questions above are true and correct to the best of my knowledge.
Signature of Master
Date