H—3lc

12

AMERICAN SAMOA, Port of Pago Pago, Samoa, , 191 To Master i of all Vessels entering: this Port :- ■• Pursuant to the regulations governing the entry of vessels into this port, you are hereby notified and directed to answer all of the questions below for the information of the Health Officer of this port. Approved : H. L. Dollard, J. M. Povkr. Health Officer of the Port. Governor of American Samoa. Name of vessel: Name of captain or master : From what port ? When did you leave above port ? En route to what port ? At what ports have you called ? Has any one been sick aboard ship (passengers or crew) within the last three weeks ? If so, what were the symptoms ( On what date and where was your vessel last fumigated ? Was any of your cargo fumigated before being received on board ? Does any of the cargo for this port need fumigating % Number of ship's crew : Number of passengers on board : Number of passengers for this port: (Signed) [Form required by Fiji Health Authorities.] QUARANTINE. [No. 13. Schedule op Questions. Questions. Answers. What is the name of the vessel ? What is the name of the officer in command ? To what port does she belong ? Whence do you come ? When did you quit your port of lading ? To what place are you bound '( At what ports or places have you touched on your voyage since you left the port of lading, and on what dates did you quit each of those places ? What vessels have you had intercourse or communication with on your passage, and. on what dates, and whence did they come, and what was the nature of the communication I Did any infectious or contagious disease exist at the place from which such vessels came ? Did any infectious or contagious disease exist at or in the vicinity of the place whence you sailed, or on board any vessel with which you had personal intercourse or communication on your passage, or at any of the places at which you have touched ? Are there any persons on board your ship affected with any infectious or contagious disease, or has any person died or been ill of a disease of that nature during the voyage ? And, if any, what number ? And if any have died or been ill of such a disease, were their bedding and clothes destroyed ? What number of officers, mariners, and passengers have you on board ? Have you any, and what, bill of health '. [Date.] [Signature of Commander, Master, or Surgeon.]

Approximate Cost of Paper. —Preparation, not given ; printing (1,000 oopies), £12 10s.

Authority : Marcus F. Marks, Government Printer, Wellington.—l9l9.

Price 6ri )