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 做鬼脸 英文 Departure date and time:
Gross tonnage (ship) room share opportunity复数 Is there ballasting water on board ? Yes □ Noworking girl□ Any radioactive cargo on board? Yes □ No □
Food and drinking water loading ports ?
Valid Sanitation Control Exemption/Control Certificate carried on board? 阿凡达经典台词Yes □ No□ Issued at date wonder boy
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 :① ② early ③ 你的眼睛在说谎
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?
(4)Is there any ill person on board now? Yes □ No□
If yes, state particulars in attached schedule.
(5)Was a medical practitioner consulted? Yesmastermind □ 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 □ 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) ?
(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□
If have, how many?
(11)Have the crew and pasngers had any the certificate of health examination for international traveler? Yes □ No□
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If have, how many?
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:
