MEDICAL CERTIFICATE FOR CRUISE SHIP PERSONNEL

SURNAME: NAME:

DATE OF BIRTH: NATIONALITY: SEX: Male Female

DECLARATION OF THE AUTHORIZED PHYSICIAN

VISION COLOUR TEST TEST HEARING

BOOK
WITHOUT GLASSESS WITH GLASSES RIGHT EAR
LANTERN
Left Eye YELLOW RED
LEFT EAR
Right Eye GREEN BLUE

Confirmation that identification documents were checked at the point of examination: YES NO
Hearing meets the standards in STCW Code, Section A-1/9? YES NO NOT APPLICABLE
Unaided hearing satisfactory? YES NO
Visual acuity meets standards in STCW Code, Section A-1/9? YES NO NOT APPLICABLE

Colour vision meets standars in STCW Code, Section A-1/9? YES NO NOT APPLICABLE

Date of last colour vision test: (Day/Month/Year)

Are glasses or contact lenses necessary to meet the required vision standards? YES NO

Able for watchkeeping (Only for Officer/Oiler/AB) YES NO NOT APPLICABLE

Is Applicant taking any non prescription or prescription medication? YES NO NOT APPLICABLE

Is The seafarers free from any medical condition likely to be aggravated by

service at sea or to render the seafarers unfit for such service or to endanger the YES NO
healt of other persons on board?

I declare that I am in knowledge of the contents of the Physical Examination and of the right to a review in accordance with MLC 2006:

Signature of applicat Name of applicant Date

Is the crewmember FIT/NOT FIT for duty WITHOUT ANY/WITH THE FOLLOWING restrictions?:

Name and degree of physician:

Address:

Name of Physician's certificating authority:

Date of Issue Physician's Certificate:

Signature of physician: Stamp of physician: Date:

Expiring date of certification:

According to MLC 2006, may be possible for the seafarer that have been refused a medical certificate or have had a limitation imposed on his/her ability to
work to request a further examination by competent authority, in line with procedures for appeal.
This certificate is issued under authorization of Panama Maritime Authority, in compliance with requirements
of STCW 78/95 Convention as amended by Maritime Labour Convention 2006 and the ILO-IMO GL 2013