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    Form 1 MDH Internasional

    Uploaded by

    Dhany Julian Syah
    This document is a maritime declaration of health form that must be completed by ship masters arriving from foreign ports. It collects information about the ship, crew, passengers and their health status. The form asks if there have been any deaths or illnesses on board, what medical treatment was provided, and sanitary measures applied. It requires listing any ports visited in the past 30 days. An attached schedule collects details about any sick individuals like their symptoms, treatment and disposition. The master must declare the information is true and sign the form, which may also be countersigned by the ship's surgeon if carried.

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    Form 1 MDH Internasional

    Uploaded by

    Dhany Julian Syah
    591 views2 pages
    This document is a maritime declaration of health form that must be completed by ship masters arriving from foreign ports. It collects information about the ship, crew, passengers and their health status. The form asks if there have been any deaths or illnesses on board, what medical treatment was provided, and sanitary measures applied. It requires listing any ports visited in the past 30 days. An attached schedule collects details about any sick individuals like their symptoms, treatment and disposition. The master must declare the information is true and sign the form, which may also be countersigned by the ship's surgeon if carried.

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    Form 1 Mdh Internasional

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    This document is a maritime declaration of health form that must be completed by ship masters arriving from foreign ports. It collects information about the ship, crew, passengers and their health status. The form asks if there have been any deaths or illnesses on board, what medical treatment was provided, and sanitary measures applied. It requires listing any ports visited in the past 30 days. An attached schedule collects details about any sick individuals like their symptoms, treatment and disposition. The master must declare the information is true and sign the form, which may also be countersigned by the ship's surgeon if carried.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    591 views2 pages

    Form 1 MDH Internasional

    Uploaded by

    Dhany Julian Syah
    This document is a maritime declaration of health form that must be completed by ship masters arriving from foreign ports. It collects information about the ship, crew, passengers and their health status. The form asks if there have been any deaths or illnesses on board, what medical treatment was provided, and sanitary measures applied. It requires listing any ports visited in the past 30 days. An attached schedule collects details about any sick individuals like their symptoms, treatment and disposition. The master must declare the information is true and sign the form, which may also be countersigned by the ship's surgeon if carried.

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    MARITIME DECLARATION OF HEALTH

    No. _______________
    To be completed and submitted to the competent authorities by the masters of ships arriving from foreign
    ports :

    Name of ports Date Anchored Time


    Name of ship’s From To

    Nationality Gross Tonnage Net Tonnage


    IMO No./ Registry
    Master’s name Port of Registry
    No.
    Ceritificate Issued at
    Sanitation Control Exemption/ Control Certificate Date Re-Inspection Yes No
    Yes Port Number of Crew
    Visit an affected area identified by the WHO No Date Number of passenger
    List ports of call from commencement of voyage with dates of departure, or within past thirty days, whichever is shorter, including all
    ports/countries visited in this period (additional names to the attached schedule)
    Name From (1) (2) (3)

    HEALTH QUESTION Yes or No


    1. Has any person died on board during the voyage oherwise than as a result to accident? (if yes, state
    particulars in attached schedule)
    2. Is there on board or has there been during the international voyage any case of disease which you suspect to be
    Of an infectious nature?
    (If yes, state particulars in attached schedule)
    3. Has the total number ill passengers during the voyage been greater than normal / expected?
    Haw many ill person? ……………..
    4. Is there any ill person on board now? (If yes, state particulars in attached schedule)
    5. Was a medical pratitioner consulted? (If yes, state particular of medical of medical treatment or advice
    Provided in attached schedule)
    6. Are you aware of any conditon on board which may lead to infectious or spread of disease?
    7. Has any sanitary measure (e.g. quarantine, isolation, disinfection or decontamination) been applied on board?
    (if yes, specify type, place and date)
    8. Have any stowaways been found on board? (if yes, where did they join the ship
    (if known))?
    9. Is there a sick animal or pet on board?

    I hereby declare that the particulars and answers to the questions given in this Declaration of Health (including the schedule) are true and correct
    to the best of may knowledge and belief.

    Signed ……………………………..
    Date ……………………………… Master

    Countersigned ……………………….
    Ship’s Surgeon (if carried)

    Note : In the absence of surgeon, the master should regard the following symptoms as grounds for suspecting the existence of a disease of an
    infectious nature
    (a) Fever, persisting for several days of accompanied by (1) prostration (2) decreased consciousness (3) glandular swelling (4) jaundice (5)
    cough or shortness of breath (6) unusual bleeding (7) paralysis
    (b) With or without fever (1) any acute skin rash of eruption (2) severe vomiting (other than sea sickness) (3) severe diarrhea (4) recurrent
    convulsions.
    SCHEDULE TO THE DECLARATION
    DRUGS
    MEDICINES OR
    REPORTED TO A
    CLASS OR PORT, DATE NATURE OF DATE OF ONSET DISPOSAL OTHER COMMENTS
    NO NAME AGE SEX NATIONALITY PORT MEDICAL
    RANTING JOINED SHIP ILLNESS OF SYMPTOMS OF CASE TREATMENT
    OFFICERS
    GIVEN TO
    PATIENT
    (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13)

     STATE : (1) whether the person recovered, is still ill or died; and (2) whether the person is still on bored, was evacuated (including the name of the port or airport), or was buried at sea

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