2014/10/28改定 0 Sta andardized d Pre-Boarrding Heallth Qu uestionnaire PUBL LIC HEAL LTH QUESTIONNA AIRE エボラ出血熱健康質問票（アジアクルーズ） Musst be compleeted by ALL persons ageed 18 and older before boarding th he ship; 乗船前までに、18才以上の乗客全員の方のご記入が必要です。1人1枚提出が必要です。 Onee form per adult a ONLY Y FOR PASSENG GERS BOARDING G IN THE UNITE ED STATES <米国から乗船になるお客様への注意文＞ This questionnaire may be reportted to the United States Centter for Disease Control and Prrevention (CDC C). Whoever know wingly and wilffully makes a materially m falsee, fictitious, or fraudulent f stattement or repreesentation may be subject to o a finee, imprisonment, or both purrsuant to Title 18, § 1001 of th he United States Code. Simillar sanctions may m apply in otherr countries wheere the information is provideed. SHIP: __ __________ ________ CA ABIN NO: ___________ _ 80333 _______ PO ORT: ______ ___________ ___ Costa Victoria Singapore Taro Yamada Name: __________ __________ ___________ __________ ________ Name(ss) of all persons under the age of 18 8 travelling with you. 18才以下の同行されるお子様の名前を記載ください。 1. Sakura Yamada 2. 3. 4. 5. 6. To assistt us in proteccting the heallth and safety of passenge ers and crew on this cruise, we require e you to answer the t following questions. 皆様に安全なクルーズを楽しんでいただくために以下の質問にお答えください。上記 のリスト上に記載したお客様の内1名でも症状があればYESを選択ください。 1) With hin the last 3 days, have you y or any off the people listed above developed d an ny symptomss of 過去3日間に下痢や嘔吐の症状があった。 diarrrhoea or vom miting? Y Yes* No 2) Do you, y or any of o the people listed above,, have a feverr or feverishn ness PLUS an ny ONE of the e following addiitional sympttoms: cough, runny nose or sore throa at? Y Yes* No 発熱の症状に加え１つでも以下の症状（咳、鼻水、のどの痛 み）があった。 (* If you answered “Y YES” to eitherr of the two questions q abo ove, you will be assessed ffree of charge e by a memberr of the shipb board Medical Staff. You will w be allowe ed to travel, unless u you arre suspected to t have an illness off internationa al public hea alth concern.)) 上記の質問に１つでもYESと答えた場合には船内医による無料追加診 断が行われます。 3) In th he past 21 da ays, have you u, or any of th he people listted above, vissited any of tthe West African 過去21日間に西アフリカの国々（リベリア、シエラレオネ、 coun ntries of Liberia, Sierra Leone, and/or Guinea? G Y Yes No ギニア）に訪問した。 4) In th he past 21 da ays have you,, or any of th he people liste ed above, been in contactt with someo one known to o or su uspected to have h Ebola, their blood orr body fluids (this ( includess working in a laboratory with sam mples from susspected Ebola patients)? 過去21日間にエボラ出血熱に感染の恐れのある人の血液、体液に接触 Y した。（研究所等での感染者サンプル取扱いも含む） Yes No 5) havee you, or any y of the people listed abovve, been in co ontact with 'M Monkeys' or 'Bats' サル、コウモリなどに接触した。 Y Yes No I certify that the abo ove declaratio on is true and d correct and d that any disshonest answ wers may havve serious public heealth implica ations. 上記の申告は正しいことをここに証明いたします。 山田 太郎 ２８Oct,2014 Signature: _______ ___________ __________ _____ Date _____ __________ ___
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