Statistics Act, 1999
R 385
International Health Regulations Act, 1974 (Act No. 28 of 1974)International Health RegulationsAppendix 4 : Maritime Declaration of Health |
(To be rendered by the masters of ships arriving from ports outside the territory)
Port of …………………………………………..Date
Name of ship ……………………………………From …………………………………..To
Nationality ……………………………………….Master's name
Net Registered Tonnage -
Deratting/Deratting Exemption Certificate………………………Dated
Issued at-
Number of passengers ………………………..Cabin………………..Number of crew
Deck-
List of ports of call from commencement of voyage with dates of departure:
HEALTH QUESTIONS
Answer "Yes" or "No"
| 1) | Has there been on board during voyage* any case or suspected case of plague, cholera, yellow fever, or smallpox? Give particulars in Schedule. |
| 2) | Has plague occurred or been suspected among the rats or mice on board during the voyage,* or has there been an abnormal mortality among them? |
| 3) | Has any person died on board during the voyage* otherwise than as a result of accident? Give particulars in Schedule. |
| 4) | Is there on board or has there been during the voyage* any case of disease which you suspect to be of an infectious nature? Give particulars in Schedule. |
| 5) | Is there any sick person on board now? Give particulars in Schedule. |
Note: In the absence of a surgeon, the Master should regard the following symptoms as ground for suspecting the existence of disease of an infectious nature: fever accompanied by prostration or persisting for several days, or attended with glandular swelling; or any acute skin rash or eruption with or without fever; severe diarrhea with symptoms of collapse; jaundice accompanied by fever.
| 6) | Are you aware of any other condition on board which may lead to infection or the spread of disease? |
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 my knowledge and belief.
Signed
Master
Countersigned
Ship's Surgeon
Date
* If more than four weeks have elapsed since the voyage began, it will suffice to give particulars for the last four weeks.
SCHEDULE TO THE DECLARATION
Particulars of every case of illness or death occurring on board.
|
Name |
Class or rating |
Age |
Sex |
Nationality |
Port of embark-ation |
Date of embark-ation |
Nature of illness |
Date of its onset |
Results of illness 1 |
Disposal of case 2 |
1 State whether recovered; still ill; died.
2 State whether still on board; landed at (give name of Port); buried at sea.
