S.L. 465.10 Art. 43Recommendations issued by WHO. To be completed Submitted at Name of ship Nationality (Flag of ship) Gross Tonnage Valid Control Issued at Re-inspection Has ship World Health Port and date List ports of past thirty days, Upon request passengers or began or within visited in this (1) Name (2) Name (3)

Any recommendation issued by WHO for specific ongoing public health risks pursuant to IHR regarding appropriate health measures for routine or periodic application needed to prevent or and submitted to the competent authorities by the masters of ships arriving from foreign ports. the port of ................................................. Date .........................

............................................... Registration / IMO No. ............... ............................. arriving from .................... sailing to ................ ............................................ Master’s name ................................

.......................................... Sanitation Control Exemption / Certificate carried on board? Yes / No ............................ date ............................ required? Yes / No visited an affected area identified by the Organization? Yes / No of visit ................................................. call from commencement of voyage with dates of departure, or within whichever is shorter: ............................................................................................................................. of the competent authority at the port of arrival, list crew members, other persons who have joined ship/vessel since international voyage past thirty days, whichever is shorter, including all ports/countries period (add additional names to the attached schedule):

................. joined from (1) ................. (2) ................. (3) ...................... ................. joined from (1) ................. (2) ................. (3) ...................... ................. joined from (1) ................. (2) ................. (3) ......................

crew members on board ......................... passengers on board ................................ Health Questions person died on board during the voyage as a result of accident? Yes / No particulars in attached schedule. Total no. of deaths ................ on board or has there been during the international of disease which you suspect to be of an infectious Yes / No particulars in attached schedule. total number of ill passengers during the voyage normal/expected? Yes / No persons? .................................... any ill person on board now? Yes / No

(6) Are you aware of any condition on board which may lead to infection or spread of disease? Yes If yes, state particulars in attached schedule.

(7) Has any sanitary measure (e.g. quarantine, isolation, disinfection or decontamination) been applied on board Yes If yes, specify place and date ...............................

(8) Have any stowaways been found on board? Yes If yes, where did they join the ship (if known)? ........................

(9) Is there a sick animal or pet on board? Yes

Note: In the absence of a surgeon, the master should regard symptoms as grounds for suspecting the evidence of a disease nature:

(a) fever, persisting for several days or accompanied by (i) decreased consciousness; (iii) glandular swelling; (iv) jaundice; shortness of breath; (vi) unusual bleeding; or (vii) paralysis;

(b) with or without fever: (i) any acute skin rash or eruption; vomiting (other than sea sickness) (iii) severe diarrhoea; convulsions.

I hereby declare that the particulars and answers to the questions Declaration of Health (including the schedule) are true and correct knowledge and belief. Signed ...........................................

Master ........................................... Countersigned ................................ Ship’s Surgeon (if carried)

Date ................................................ vessel given to patient whether the person recovered, is still ill or died; and (2) whether the person is evacuated (including the name of the port or airport), or was buried at sea. This Certificate records the inspection and 1) exemption from control measures applied Name of ship or inland navigation vessel ............................... Flag Registration/IMO No .................................... At the time of inspection the holds were unladen/laden with ............. cargo Name and address of inspecting officer ............................

Ship Sanitation Control Exemption Certificate Ship Sanitation Control Areas, (systems Evidence Sample Documents Control Re-inspection and services) found 1 results 2 reviewed measures date inspected applied

Galley Pantry Stores Hold(s) / cargo Quarters: - crew - officers - passengers - deck Potable water Sewage Ballast tanks Solid and medical waste Standing water Engine room Medical facilities Other areas specified - see attached Note areas not applicable, by marking N/A No evidence found. Ship/vessel is exempted from Control measures indicated control measures the date below.

Name and designation of inspecting officer Signature and seal

1

(a) Evidence of infection or contamination, including: vectors in all stages reservoirs for vectors; rodents or other species that could carry human disease; microbiological, and other risks to human health; signs of inadequate sanitary measures. (b) Intormation human cases (to be included in the Maritime Declaration of Health). 2 Results from samples taken on board. Analysis to be provided to ship’s master means and, if re-inspection is required, to the next appropriate port of call coinciding TO SHIP SANITATION CONTROL EXEMPTION CERTIFICATE / SHIP SANITATION CONTROL CERTIFICATE

Control Exemption Certificate Ship Sanitation Control Certificate / Evidence Sample Documents Control Re-inspection Comments found 1 results 2 reviewed measures date regarding applied conditions found spas areas listed are not applicable by marking N/A Net Tonnage Fees Up to 1,000 tons €55 Over 1,000 to 3,000 tons €77 Over 3,000 to 10,000 tons €99 Over 10,000 to 20,000 tons €121 Over 20,000 to 50,000 tons €143 Over 50,000 tons €165

SCHEDULE 4