Einde inhoudsopgave
International Health Regulations
Appendix 3
Geldend
Geldend vanaf 01-01-1982
- Redactionele toelichting
Voorheen aanhangsel 4. Oorspronkelijk aanhangsel 3 vervallen. In het Tractatenblad wordt aanhangsel 5 i.p.v. aanhangsel 4 vernummerd.
- Bronpublicatie:
20-05-1981, Trb. 1981, 192 (uitgifte: 31-08-1981, kamerstukken/regelingnummer: -)
- Inwerkingtreding
01-01-1982
- Bronpublicatie inwerkingtreding:
20-05-1981, Trb. 1981, 192 (uitgifte: 31-08-1981, kamerstukken/regelingnummer: -)
- Vakgebied(en)
Gezondheidsrecht / Individuele gezondheidszorg
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 or | Certificate … | Dated … | |
Deratting Exemption | Issued at … | ||
Number of | Cabin … | Number of crew … | |
passengers | Deck … | ||
List of ports of call from commencement of voyage with dates of departure:
…
…
Answer Yes or No | ||||
|---|---|---|---|---|
1. | Has there been on board during the voyage *any case or suspected case of plague, cholera, or yellow fever? Give particulars in the 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 diarrhoea 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 … | ||||
Schedule to the declaration
Particulars of every case of illness or death occurring on board
Name | Class or rating | Age | Sex | Nationality | Port of embarkation | Date of embarkation | Nature of illness | Date of its onset | Results of illness *) | Disposal of case **) |
|---|---|---|---|---|---|---|---|---|---|---|
Voetnoten
If more than four weeks have elapsed since the voyage began, it will suffice to give particulars for the last four weeks.
If more than four weeks have elapsed since the voyage began, it will suffice to give particulars for the last four weeks.
If more than four weeks have elapsed since the voyage began, it will suffice to give particulars for the last four weeks.
If more than four weeks have elapsed since the voyage began, it will suffice to give particulars for the last four weeks.
State whether recovered; still ill; died.
State whether still on board; landed at (give name of port); buried at sea.