MA

RIT

IME

DE

CL

AR

AT

ION

OF H

EA

LT

H

APPE

ND

IX 5 (C

ON

TIN

UE

D)

SCH

ED

UL

E T

O T

HE

DE

CL

AR

AT

ION

PA

RT

ICU

LA

RS O

F EV

ER

Y C

ASE

OF IL

LN

ESS O

R D

EA

TH

OC

CU

RR

ING

ON

BO

AR

D

N

AM

E

CL

ASS

OF

RA

TIN

G

AG

E

SEX

N

AT

ION

AL

ITY

D

AT

E O

F EM

BA

RK

ING

N

AT

UR

E O

F IL

NE

SS D

AT

E O

F OFF-SE

T

RE

SUL

T O

F IL

NE

SS D

ISPOSA

L O

F C

ASE

*State whether recovered:_______ Still Ill:______ D

ied: ______

______________________________

MA

STER’S SIG

NA

TUR

E