Page:United States Statutes at Large Volume 59 Part 2.djvu/308

 974 TREATIES [59 STAT. International Sanitary Convention, 1944 MARITIME DECLARATION OF HEALTH (International Form) (To be rendered by the masters of ships arriving from ports outside the Territory.) Port of Date Name of Vessel From to Nationality Master's Name Net Registered Tonnage Deratization or] Certificate Dated Deratization Exemption J Issued at No. of- Passen- Cabin No. of Crew gers JDeck 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 the voyage* any case or suspected case of plague, cholera, yellow fever, typhus fever, or smallpox? 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 unusual mortality among them? 3. Has any person died on board during the voyage* other- wise 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 illness 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 exist- ence of infectious disease: 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 infectious 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 Date Ship's surgeon weeks.
 * If more than 6weeks have elapsed since the voyage began, it will suffice to give particulars for the las 6

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