2754

THE NEW ZEALAND GAZETTE

[No. 97

Form (3).
ORDER FOR SHIP TO PERFORM QUARANTINE.
Under Section 112 of the Health Act, 1920.
Port of
To , Master of [State class of ship and name].
In pursuance of the power conferred on me by section 112 of
the Health Act, 1920, I hereby order the [State class of ship
and name] into quarantine, together with all persons and
goods on board the vessel.
Given under my hand this day of , 192 .
Port Health Officer.

Form (4).
ORDER FOR PERSON TO PERFORM QUARANTINE.
Under Section 115 of the Health Act, 1920.
Port of
To .
In pursuance of the power conferred on me by section 115
of the Health Act, 1920, I hereby order into quarantine.
Given under my hand this day of , 192 .
Port Health Officer.

Form (5).
ORDER FOR GOODS TO BE SUBJECTED TO QUARANTINE.
Under Section 119 of the Health Act, 1920.
To .
In pursuance of the power conferred on me by section 119
of the Health Act, 1920, I hereby order into quarantine the
following goods which are on the ship whereof you are master
[or of which you are or appear to be the owner, consignee,
possessor, or custodian]:
Given under my hand this day of , 192 .
Port Health Officer.

Form (6).
CERTIFICATE OF RELEASE FROM QUARANTINE.
Under Section 127 of the Health Act, 1920.
I HEREBY certify that [Here state name of ship or person]
has duly performed quarantine, and being free from the
infection of any infectious disease is released from quarantine.
Given under my hand this day of , 192 .
Medical Officer of Health.

Form (7).
CERTIFICATE OF RELEASE FROM QUARANTINE.
Under Section 127 of the Health Act, 1920.
I HEREBY certify that the following goods, of which you
are or appear to be the owner, consignee, possessor, or
custodian, have duly performed quarantine, and being free
from the infection of infectious disease are released from
quarantine:
Given under my hand this day of , 192 .
Medical Officer of Health.

Form (8).
UNDERTAKING AS TO EXPENSES INCURRED IN REMOVAL
OF PERSONS FROM SHIP TO HOSPITAL OR PLACE OF
ISOLATION.
Under Section 111 of the Health Act, 1920.
I [We], , of , being the master [or owner,
or agents] of the [Class and name of ship], at present
in the Port of , in consideration of the persons
mentioned hereunder being removed to a public hospital or
place of isolation for treatment or isolation, hereby under-
take to pay for all expenses incurred for all services rendered
in connection with the removal, isolation, maintenance, and
treatment of the said persons, of whom particulars are set
out hereunder:—
Name of Person. Reason for Removal. Date removed from
Vessel to Hospital.
(Signed)
Master [or Owner, or Agents] of the Ship.
Dated , 192 .

Form (9).
UNDERTAKING OF MASTER OF SHIP IN RESPECT OF A PERSON
DETAINED ON BOARD.
Under Section 111 of the Health Act, 1920.
I, , Master of the [Class and name of ship],
at present in the Port of , do hereby undertake to
observe the instructions of the Port Health Officer, as set
out hereunder, in regard to the detention on board of the
persons mentioned hereunder.
Name of Person. Reason for Detention. Instructions.*

• To be filled in by the Port Health Officer.
  (Signed) , Master.
  Dated , 192 .
  Witness

Form (10).
UNDERTAKING OF PERSON RELEASED UNDER MEDICAL
SURVEILLANCE.
I, , at present on board the ship , and
liable to quarantine, hereby undertake, if released under
medical surveillance, to faithfully comply with the regula-
tions relating to release under medical surveillance, and to
report myself to the Medical Practitioner and at the times
and places indicated hereunder:—
Places at which Person shall Medical Practitioner Dates on which
report for to whom he shall he shall report.
Medical Examination. report.
(To be filled in by the Medical Officer of Health.)
My address during the ensuing days will be .
[Date.] [Signature.]
NOTE.—It will be sufficient if this undertaking be signed
by the head of a family in cases where more than one member
of a family desire to leave under surveillance, provided every
member above twenty-one years of age must give a separate
undertaking.

Form (11).
ORDER TO MASTER TO CLEANSE, FUMIGATE, OR DISINFECT
THE SHIP.
Under Section 128 of the Health Act, 1920.
To , Master of [Insert name and class of ship].
In my opinion the above-mentioned ship is in an insanitary
condition [in a condition favourable to the outbreak or
spread of a notifiable infectious disease], and in accordance
with the above section I hereby order the said vessel to be
taken to [State place to which ship shall be taken] and there
[State process in detail of cleansing, fumigating, or disinfection],
within [State time within which work shall be done].
Given under my hand this day of , 192 .
Port Health Officer.

Form (12).
OUTWARD BILL OF HEALTH.
Vessel :
Issued at the Port of . Nationality:
Vessel clearing for Registered tonnage :
Master:
Surgeon :
Date of arrival at this port :
Date of departure:
Number of (a) Crew ; (b) Passengers—1st
2nd , 3rd
Sanitary measures taken at this port:—
(a.) Vessel not quarantined [quarantined on account of
(See Statement I on back of form)].
(b.) Vessel not disinfected [disinfected on account of
(See Statement II on back of form)].
(c.) Rodent destruction measures carried out (See separate
Fumigation Certificate).
(d.) Number and nature of cases of infectious disease
removed for isolation at this port: