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

Maritime Declaration of Health form (Maritieme Gezondheidsverklaringsformulier)

Agent of ship at intended port of arrival

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):

Health questions

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.