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Pratique Application

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Please fill out the following forms in order to participate in our activity. Submissions are valid up to 90 hours TBA

Name of vessel

Estimated Time of Arrival.

Last Port(s) going back 30 days, with Departure dates.

Next Port.

Number of Crew / Passengers.

Number of Animals / Pets. Health condition?

Health Status of Ship and persons, considering the following health questions

Health questions

Has any person died on board during the voyage otherwise than as a result of accident? If yes, state particulars

Yes

State Particulars

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

Yes

State Particulars

Is there any ill person on board now? If yes, state particulars

Are you aware of any condition on board, which may lead to infection or spread of disease? If yes, state particulars.

Yes

State particulars

Date

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 infectious 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) severe vomiting (other than sea sickness); (iii) severe diarrhoea; or (iv) recurrent convulsions.

Ship’s contact details :

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.