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GOVERNMENT OF INDIA

MINISTRY OF HEALTH & FAMILY WELFARE


MARITIME DECLARATION OF HEALTH
(To be completed and submitted to the competent authorities by the Masters of the vessel arriving from the foreign ports)
Submitted at the port of .Date.
Name of the Ship or Inland navigation vessel.egistration No!IM" No..
#rriving from.Sailing to.
Nationality ($lag) of the vessel.. Master%s Name..
&ross Tonnage..Tonnage inland navigation vessel
'alid Sanitation (ontrol )*emption!(ontrol (ertificate carried on board+ ,es!No
Issued at..Date...
e-Inspection re.uired+ ,es!No..
/as ship!vessel visited an affected area identified by the 0orld /ealth "rganisation+ ,es!No.
1ort and date of visit.
2ist ports of call from the commencement of voyage 3ith dates of departure4 or 3ithin past thirty days4 3hichever is shorter.

5pon re.uest of the competent authority at the port of arrival4 list cre3 members4 passengers or other persons 3ho have 6oined
ship!vessel since international voyage began or 3ithin past thirty days4 3hichever is shorter4 including all ports!countries
visited in this period7add additional names to the attached schedule)
1ort Date of 8oining Nationality
(9) Name.6oined from (9) .. (:). (;)
(:) Name.6oined from (9)... (:). (;)
(;) Name 6oined from(9).(:).(;)
Number of cre3 members on board.
Number of passengers on board
/ealth <uestions
(9) /as any person died on board during the voyage other3ise than as a result of accident+ ,es!No
If yes4 state particulars in attached schedule. Total no. of deaths
(:) Is there on board or has there been during international voyage any case of disease 3hich you suspect to be of an
Infectious nature+ ,es!No4 If yes4 state particulars in attached schedule
(;) /as the total number of ill passengers during the voyage been greater than normal!e*cepted+ ,es!No
/o3 many ill persons+.............
(=) Is there any ill persons on board no3+ ,es!No If yes4 state particulars in attached schedule
(>) 0as a medical practitioner consulted+ ,es!No If yes4 state particulars of medical treatment or advice provided in attached
schedule
(?) #re you a3are of any condition on board 3hich may lead to infection or spread of disease+ ,es!No If yes4 state
particulars in attached schedule
(@) /as any sanitary measures (e.g. .uarantine4 isolation4 disinfection or decontamination) been applied on board+ ,es!No If
yes4 state particulars in attached schedule
(A) /as any sto3ays been found on board+ ,es!No If yes4 3here did they 6oin the ship (if Bno3n)+.............................................
(C) Is there a sicB animal or pet on board+ ,es!no
(9D)/as the Ship touched any ports in the ,ello3 $ever )ndemic (ountries in the last ;D days4 before arrival+ ,es!No (If yes
provide details of 1ort.(ountry..departure date.
NoteE In the absence of a surgeon4 the Master should regard the follo3ing symptoms as grounds for suspecting the e*istence
of a disease of an infectious natureE
(a) fever4 persisting for several days or accompanied by(i)prostration(ii) decreased consciousness(iii) glandular
s3ellingE
(iv) 8aundice (v) cough or shortness of breathE (vi) unusual bleedingE or (vii) paralysis.
(b) 3ith or 3ithout feverE (i) any acute sBin rash or eruption(ii) severe vomiting (other than sea sicBness)(iii) severe
diarrhoeaE or (iv) recurrent convulsion
I hereby declare the particulars and ans3ers to the .uestions given in this Declaration of /ealth (including the schedule) are
true and correct to the best of my Bno3ledge and belief.
Signed..
Master
(ountersigned
Date.. Ship%s Surgeon (if carried)

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