verba-红玫瑰的英文
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 vessel
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/vessel 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, passengers or other persons who have joined ship/ves-
sel 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
③
Number of crew members on board Number of passengers on board
Health questions
(1) Has any person died on board during the voyage otherwise 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 disease
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 passengers 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?
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 disease?
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 passengers had any the certificate of vaccination?
Yes
□
No
□
If have, how many?
(11)Have the crew and passengers had any the certificate of health examination for international traveler?
Yes
□
No
□
If have, how many?
Note: In the absence of a surgeon , the master should regard the following symptoms as grounds for suspecting the existence of a disease of an infection
nature:
(a) fever,
persisting for several days or accompanied by
(i)
prostration;
(ii)
decreased consciousness;
(iii)
glandular swelling;
(iv)
jaundice
(v)
cough or shortness or breath;
(iv ) unusual bleeding or
(vii)
paralysis
(b) with or without fever : (i)
any acute skin rash or eruption
(ii)
severe vomiting (other than sea sickness)
(iii) severe diarrhoea or
( iv )
re-
current convulsions.
I hereby declare that the particulars and answers to the questions given in this Declaration of Health (including the schedule) are sure
and correct to the best of my knowledge and belief.
Date
Signature of Captain
Countersignature of Ship’s Surgeon (i
f carried)
[1-4e(2008.1.1)*1]
verba-红玫瑰的英文
verba-红玫瑰的英文
verba-红玫瑰的英文
verba-红玫瑰的英文
verba-红玫瑰的英文
verba-红玫瑰的英文
verba-红玫瑰的英文
verba-红玫瑰的英文
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