THE MARITIME DECLARATION OF HEALTH FORM

This form is intended for all vessels navigating on Surinamese waters.

Maritime Declaration of Health form (Maritieme Gezondheidsverklaringsformulier)

Submitted at the port of

Date

Name of Ship

Registration/IMO Number

Arriving from

Sailing to

Nationality (flag of vessel)

Master’s name

Gross tonnage (ship)

Tonnage (inland navigation vessel)

Agent of ship at intended port of arrival

Valid Sanitation Control Exemption / Control Certificate carried on board?

Issued By

Sanitation Control Date

Re-inspection required

Has ship/vessel visited an affected area identifed by the World Health Organization?

Port and date of visit WHO

List ports of call from commencement of voyage with dates of departure, or within past thirty days; whichever is shorter

Upon request of the competent authority at the port of arrival, list crew members, passengers or other persons who have joined ship/vessel since international voyage began or within past thirty days, which ever is shorter, including all ports/countries visited in this period (add additional names to the attached schedule):

Name person

Joined from

Number of crew members on board

Number of passengers on board

Health questions

Has any person died on board the ship during the voyage otherwise than as a result of accident?

Is there on board or has there been during the international voyage any case of disease which you suspect to be of an infectious nature?

Has the total number of sick passengers during the voyage been greater than normal/expected?

How many sick persons?

Is there any ill person on board now?

If yes, state particulars of medical treatment or advice provided:

Are you aware of any condition on board which may lead to infection or spread of disease?

Has any sanitary measure (e.g quarantine, isolation, disinfection or decontamination) been applied on board?

If yes, specify type, place and date

Have any stowaways been found on board?

If yes, where did they join the ship (if known)

Is there a sick animal or pet on board?

Note: In the absence of a surgeon ,the master should regard the following symptons as grounds for suspecting the existence of a disease of an infectious nature :

Fever, persisting for several days or accompanied by (!) prostration (!!) decreased conciousness; (!!! ) glandular swelling; (!V) jaundice; (V) cough or shortness of breath; (V!) unusual bleeding; or (V!!) paralysis.

With or without fever: (!) any acute skin rash or eruption (!!) severe vomiting (other than sea sickness); (!!! ) severe diarrhoea; or (!V) recurrent convulsions.

Signed (Master)

Countersigned (Ship’s Surgeoan (if carried))

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