航海健康申报书.docVIP

中华人民共和国出入境检验检疫 航海健康申报书 MARITIME DECLARATION OF HEALTH Entry-Exit Inspection and Quarantine of the P. R. of China 抵/离港port of Arrival/Departure________________________________________来自到/From/To 抵/离日期及时间Time and Date of Arrival/Departure 船名Name of ship___________________国籍Nationality____________________船长姓名Name of Captain 注册净吨位Net Tons______________________________载货种类及数量Description and Quantity of cargo 除鼠/免予除鼠证书Deratting/Deratting/Exemption Certificate_____________是否有压舱水Ballast Water ?Yes ?No 签发港及日期Port and Date of Issue__________________________食物装载港Port of Provisions Taken_________________________ 船员人数Number of Crew_____旅客人数Number of Passengers____饮水装载港Port of Water Taken 船舶在港期间人员变动情况Description of any change of crew while in port2 沿途寄港及到达离去日期Ports of Call with Dates of Arrival and Dates of Departure3 健康问题 回答有或无 HEALTH QUESTIONS ANSWER YES OR NO 1．船上有无发现鼠疫、霍乱、黄热病等病例或疑似病例？应用附表详细记载。 Has there been on board any case or suspected case of plague, cholera or yellow fever? Give particulars in schedule. ? 有 Yes ? 没有 No 2．船上鼠类曾否发生鼠疫或疑似鼠疫，或曾否发生鼠类反常死亡？ Has plague occurred or been suspected among the rats or mice on mice ? 有 Yes ? 没有 No on board,or has there been an abnormality among them? 3．除意外伤害外，船上曾否有人死亡？应用附表详细记载。 Has any person died on board otherwise than as a result of accidents? ? 有 Yes ? 没有 No Give particulars in schedule 4．除问题