Last Name: First Name: Work Status:

Nationality: [ ] New Hire

Date of Birth ( Day/Month/Year): Gender [ ] Re Hire
Passport or Crew Identification #: [ ] Male [ ] Female [ ] Returning
Position on board:
MEDICAL CERTIFICATE FOR SERVICE AT SEA
On the basis of the examinee's personal declaration, my clinical examination and diagnostic test results
recorded on the medical examination form, I declare the examinee:
Fit for Duty [ ] Unfit for Duty
[ ] Without Restriction
[ ] With Restriction

List Restrictions:

Does the seafarer have any medical condition likely to be aggravated by service at sea or might
endanger others onboard? [ ] Yes [ ] No
If YES, must explain:

Hearing meets standards: [ ] Yes [ ] No Deck & engine seafarers only:

Visual acuity meets standards: [ ] Yes [ ] No Normal color vision exam within the past
Proof of MMR Immunity on file [ ] Yes [ ] No 6 years: [ ] Yes [ ] No

Official stamp of either medical facility or medical examiner:

Seafarer's
Photo
Print name of Medical Examiner:_________________________________
Signature of Medical Examiner:__________________________________
Name of medical Facility:____________________________________
Location of medical Facility: __________________________________
Date of the exam: _____/_____/____
Day/Month/Year

Expiration Date:_____/_____/_____ (expires two years from the examination date)

Day/Month/Year

This document is in accordance with STCW regulation I/9 or ILO-73 ( 1946 ) or ILO-147 ( 1976 ) or ILO/IMO
or ILO Maritime Labour Convention 2006 ( MLC-2006 ) " Guidance on the Medical Examination for Seafarers ".

Rev 02 / 2013