ENTRY-EXIT INSPECTION AND QUARANTINE
OF THE PEOPLES REPUBLIC OF CHINA
MARITIME DECLARATION OF HEALTH
To be completed and submitted to the competent authorities of Inspection
and Quarantine by the master of entry-exit ships
Submitted at the port of Date
Name of ship or inland navigation vesl IMO No Nationality Master’s name
Entry ship: Arriving from Arrival date and time:
Exit ship: Sailing to Departure date and time:
Gross tonnage (ship) Is there ballasting water on board ? Yes □ No□ Any radioactive cargo on board? Yes □ No □
Food and drinking water loading ports ?
Valid Sanitation Control Exemption/Control Certificate carried on board? Yes □ No□ Issued at date
Has ship/vesl visited an affected area identified by the World Health Organization? Yes □ No□ If yes, port and date of visit
List ports of call from commencement of voyage with dates of departure, or within past four weeks, whichever is shorter:
Upon request of the competent authority at the port of arrival, list crew members, pasngers or other persons who have joined ship/ves-
l since international voyage began or within past four weeks, whichever is shorter, including all ports/countries visited in this period
( add additional names to the attached schedule):
(1) Name joined from :① ② ③
(2) Name joined from :① ② ③
(3) Name joined from 古典音乐会:① ② ③
Number of crew members on board Number of pasngers on board
Health questions
(1) Has any person died on board during the voyage otherwi than as a result of accident？ Yes □ No□
If yes, state particulars in attached schedule. Total No. of deaths.
(2)Is there on board or has there been during the international voyage any cast of dia
Which you suspect to be of an infectious nature? Yes □ No□
If yes, state particulars in attached schedule.
(3)Has the total number of ill pasngers during the voyage been greater than normal/expected?
How many ill persons？ persons?对联广告
(4)Is there any ill person on board now? Yes □ No家族群名称大全□
If yes, state particulars in attached schedule.
(5)Was a medical practitioner consulted? Yes □ No□
If yes, state particulars of medical treatment or advice provided in attached schedule.
(6)Are you aware of any condition on board which may lead to infection or spread of dia? Yes □ No□
If yes, state particulars in attached schedule.
(7)Has any sanitary measure (e.g. quarantine ,isolation disinfection or decontamination) been applied on board? Yes 红杉树□水平定向钻机 No□
If yes, specify type, place and date
(8)Have any stowaways been found on board? Yes □ No□
If yes, where did they join the ship (if known) ? 为什么会散光
(9)Is there a sick animal or pet on board ? Yes □ No□
(10)Have the crew and pasngers had any the certificate of vaccination? Yes □ No□
100法郎 If have, how many?
(11)Have the crew and pasngers had any the certificate of health examination for international traveler? Yes □ No□
If have, how many? 霸气的网名男生
Note: In the abnce of a surgeon , the master should regard the following symptoms as grounds for suspecting the existence of a dia of an infection nature:
