MARITIME DECLARTION OF HEALTH
To be completed and submitted to the competent authorities by the masters of ships arriving from foreign
ports
Submitted at the Port of…KHORFAKKAN Date
Name of ship or inland navigation vessel…MT MAREN Registration/IMO No. 9365776
Arriving from…SINGAPORE Sailing to…… TBA……..……..
(Nationality) (Flag of vessel)… PANAMA ……… Master’s Name…CAPT. YASIR NOOR MALIK …
Gross Tonnage (ship)…163330
Tonnage (inland navigation vessel) ……
Valid Sanitation Control Exemption/Control Certificate on board? Yes...issued at …………, …….…Date
…………..
Has ship/vessel visited an affected area identified by the World Health Organization? No……
Port and date of visit………NA…………………..
List of ports of call from commencement of voyage with dates of departure, or within past
thirty days, whichever is shorter.
…SINGAPORE ……………………………………………………
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,
Whichever is shorter, including all ports/countries visited in this period (add additional names
to be attached schedule):-
Number of crew members on board…28……
Number of passengers on board ……0….…
Health questions
(1) Has any person died on board during the voyage otherwise than as a result of accident? No….
If yes, state particulars in attached schedule Total No. of deaths…NONE….
(2) Is there on board or has there been during the international voyage any case of disease
which you suspect to be of an infections nature? NO ...if yes, state particulars in attached schedule.
(3) Has the total number of ill passengers during the voyage been greater than normal/expected? NO..
(4) Is there any ill person on board now?. NO ………If yes, state particulars is attached schedule.
(5) Was a medical practitioner consulted? NA……… 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 disease?
NO………. If yes, state particulars in attached schedule.
(7) Has any sanitary measure (e.g. quarantine, isolation, disinfection or decontamination) been applied
On board? …NO………… If yes, specify type, place and date…:
(8) Have any stowaways been found on board? …No……..If yes, where did they join the ship(if known)?
(9) is there a sick animal or pet on board? …….No…..
Note: In the absence of a surgeon, the master should regard the following symptoms as ground for
suspecting the existence of a disease of an infections nature:-
(a) fever, persisting for several days or accompanied by (i) prostration;(ii)decreased consciousness;
(iii) glandular swelling; (iv) jaundice; (v) cough or shortness of breath
(vi) unusual bleeding; or ((vii) paralysis
(b) with or without fever; (i) any acute skin rash or eruption; (ii) sever vomiting (other than sea
sickness); (iii) Severe diarrhea; or (iv) recurrent convulsions.
I hereby declare that the particulars and answers to the questions given in this Declaration of Health
(including the schedule) are true and c Signed…………………….
Master
Countersigned…………………..
Ship’s Surgeon (if carried)
Ship’s Stamp Date…………………………..
