SEAFARERS MEDICAL EXAMINATION REPORT/CERTIFICATE

This certificate is issued by authority of the Maritime Administrator and in compliance with the requirements of the Medical Examination (Seafarers) Convention
1946 (ILO No. 73), as amended, STCW Convention, 1978 as amended and the Maritime Labor Convention, 2006.
SURNAME: GIVEN NAME (S):

NATIONALITY: ID DOCUMENT NO:

DATE OF BIRTH: PLACE OF BIRTH: SEX:

MALE FEMALE
MONTH DAY YEAR CITY COUNTRY
EXAMINATION FOR DUTY AS: MAILING ADDRESS OF APPLICANT:
MASTER
DECK OFFICER
ENGINEERING OFFICER
RADIO OFFICER
RATING
DECLARATION OF APPROVED MEDICAL PRACTIONER:
I CONFIRM THAT IDENTIFICATION DOCUMENTS WERE
YES NO
CHECKED:
MEDICAL EXAMINATION (SEE LAST PAGE FOR MEDICAL REQUIREMENTS) STATE DETAILS ON REVERSE SIDE
HEIGHT WEIGHT BLOOD PRESSURE PULSE RESPIRATION GENERAL APPEARANCE

VISION: HEARING
RIGHT EYE LEFT EYE RT. EAR LEFT EAR
WITHOUT
/
GLASSES
WITH GLASSES /

CHECK IF COLOR TEST IS YELLOW RED GREEN BLUE

COLOR TEST TYPE: BOOK LANTERN NORMAL
DATE OF LAST COLOR VISION TEST:
ARE GLASSES OR CONTACT LENSES NECESSARY TO MEET THE REQUIRED VISION STANDARD? YES NO
HEAD AND NECK HEART (CARDIOVASCULAR)

LUNGS SPEECH (DECK/NAVIGATIONAL OFFICER AND RADIO OFFICER)

IS SPEECH UNIMPAIRED FOR NORMAL VOICE COMMUNICATION?

EXTREMITIES:
UPPER LOWER

IS APPLICANT VACCINATED IN ACCORDANCE WITH WHO REQUIREMENTS? YES NO

IS APPLICANT SUFFERING FROM ANY DISEASE LIKELY TO BE AGGRAVATED BY
WORKING ABOARD A VESSEL, OR TO RENDER HIM/HER UNFIT FOR SERVICE AT SEA YES NO
OR LIKELY TO ENDANGER THE HEALTH OF OTHER PERSONS ON BOARD?
IS APPLICANT TAKING ANY NON-PRESCRIPTION OR PRESCRIPTION MEDICATIONS? YES NO

SIGNATURE OF APPLICANT DATE

THIS SIGNATURE SHOULD BE AFFIXED IN THE PRESENCE OF THE EXAMINING PHYSICIAN.

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 THIS IS TO CERTIFY THAT A PHYSICAL EXAMINATION WAS GIVEN TO:
NAME OF APPLICANT

THIS APPLICANT IS CERTIFIED FREE OF COMMUNICABLE DISEASE: YES NO

HEARING MEETS THE STANDARDS IN SECTION A I/9: YES NO
UNAIDED HEARING SATISFACTORY: YES NO
VISUAL ACUITY MEETS STANDARDS IN SECTION A I/9: YES NO
COLOUR VISION MEETS STANDARDS IN SECTION A I/9: YES NO

TICK APPROPRIATE CHOICE: HE / SHE IS FOUND TO BE FIT / NOT FIT FOR DUTY AS A MASTER / DECK
OFFICER / ENGINEERING OFFICER / RADIO OFFICER / ELECTRICAL ENGINEER (ELECTRICIAN) / RATING
WITHOUT ANY / WITH THE FOLLOWING RESTRICTIONS:

NAME AND DEGREE OF PHYSICIAN:

ADDRESS OF MEDICAL CENTER:

NAME OF PHYSICIANS CERTIFICATING AUTHORITY:

DATE OF ISSUE OF PHYSICIANS CERTIFICATE:

SIGNATURE OF PHYSICIAN:

DATE OF EXAMINATION:

EXPIRY DATE OF CERTIFICATE:

SEAFARER ACKNOWLEDGMENT:

I, (NAME OF SEAFARER), CONFIRM THAT I HAVE BEEN INFORMED

OF THE CONTENT OF CERTIFICATE AND THE RIGHT TO GET A REVIEW.

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 MEDICAL REQUIREMENTS

This physical examination must be carried out not more than 24 months prior next medical check for a seafarer older than 18 years old and
considered to be fit for duty without any restrictions. In case of any restriction found not preventing seafarer to fulfill his duties this physical
examination should be carried out not more than 12 months prior next medical check. The examination shall be conducted in accordance with
the International Labor Organization World Health Organization, Guidelines for Conducting Pre-sea and Periodic Medical Fitness
Examinations for Seafarers (ILO 73/WHO/D.2/1997, STCW Convention, 1978 as amended and the Maritime Labor Convention, 2006. Such
proof of examination must establish that the applicant is in satisfactory physical and mental condition for the specific duty assignment
undertaken and is generally in possession of all body faculties necessary in fulfilling the requirements of the seafaring profession.

In conducting the examination, the certified physician should, where appropriate, examine the seafarers previous medical records (including
vaccinations) and information on occupational history, noting any diseases, including alcohol or drug-related problems and/or injuries. In
addition, the following minimum requirements shall apply:
a) Hearing
All applicants must have hearing unimpaired for normal sounds and be capable of hearing a whispered voice in better ear at 15 feet
(4.57 m) and in poorer ear at 5 feet (1.52 m).
b) Eyesight
Deck officer applicants must have (either with or without glasses) at least 20/20 (1.00) vision in one eye and at least 20/40 (0.50) in
the other. If the applicant wears glasses, he must have vision without glasses of at least 20/160 (0.13) in both eyes. Deck officer
applicants must also have normal color perception and be capable of distinguishing the colors red, green, blue and yellow.
Engineer and radio officer applicants must have (either with or without glasses) at least 20/30 (0.63) vision in one eye and at least
20/50 (0.40) in the other. If the applicant wears glasses, he must have vision without glasses of at least 20/200 (0.10) in both eyes.
Engineer and radio officer applicants must also be able to perceive the colors red, yellow and green.
c) Dental
Seafarers must be free from infections of the mouth cavity or gums.
d) Blood Pressure
An applicant's blood pressure must fall within an average range, taking age into consideration.
e) Voice
Deck/Navigational officer applicants and Radio officer applicants must have speech which is unimpaired for normal voice
communication.
f) Vaccinations
All applicants shall be vaccinated according to the requirements indicated in the WHO publication, International Travel and Health,
Vaccination Requirements and Health Advice, and shall be given advice by the certified physician on immunizations. If new
vaccinations are given, these shall be recorded.
g) Diseases or Conditions
Applicants afflicted with any of the following diseases or conditions shall be disqualified: epilepsy, insanity, senility, alcoholism,
tuberculosis, acenereal disease or neurosyphilis, AIDS, and/or the use of narcotics. Applicants diagnosed with, suspected of, or
exposed to any communicable disease transmittable by food shall be restricted from working with food or in food related areas until
symptom-free for at least 48 hours.
h) Physical Requirements
Applicants for able seaman, bosun, GP-1, ordinary seaman and junior ordinary seaman must meet the physical requirements for a
deck/navigational officer's certificate.
Applicants for fireman/water tender, oiler/motorman, pumpman, electrician, wiper, tankerman and survival craft/rescue boat crewman
must meet the physical requirements for an engineer officer's certificate.
IMPORTANT NOTE

The seafarer must retain the original of the Medical Examination Report/Certificate as evidence of physical qualification while serving on
board a vessel.
An applicant who has been refused a medical certificate or has had a limitation imposed on his/her ability to work, shall be given the
opportunity to have an additional examination by another medical practitioner or medical referee who is independent of the shipowner or of any
organization of shipowners or seafarers.
Medical examination reports shall be marked as and remain confidential with the applicant having the fight of a copy to his/report. The medical
examination report shall be used only for determining the fitness of the seafarer for work and enhancing health care.
DETAILS OF MEDICAL EXAMINATION

(To be completed by examining physician; alternatively the examining physician may attach a form similar or identical to the model provided
Medical Exam Form).

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