PHYSICAL EXAMINATION REPORT/CERTIFICATE

OFFICE OF THE MARITIME ADMINISTRATOR

CONFIDENTIAL DOCUMENT

SURNAME GIVEN NAME(S)

DATE OF BIRTH PLACE OF BIRTH SEX

MONTH DAY YEAR CITY COUNTRY MALE FEMALE

EXAMINATION FOR DUTY AS: MAILING ADDRESS OF APPLICANT:

MASTER
DECK OFFICER
ENGINEERING OFFICER
RADIO OFF
RATING

MEDICAL EXAMINATION (SEE REVERSE SIDE FOR MEDICAL REQUIREMENTS) STATE DETAILS ON REVERSE SIDE
HEIGHT WEIGHT BLOOD PRESSURE PULSE RESPIRATION GENERAL APPEARANCE

VISION: RIGHT EYE LEFT EYE HEARING:

WITHOUT GLASSES /
WITH GLASSES / RT. EAR LEFT EAR

COLOR TEST TYPE: BOOK LANTERN CHECK IF COLOR TEST IS NORMAL - YELLOW RED GREEN BLUE
ARE GLASSES OR CONTACT LENSES NECESSARY TO MEET THE REQUIRED VISION STANDARDS? 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 ILLNESS OR DISEASE LIKELY TO BE AGGRAVATED BY WORKING ABOARD A VESSEL, OR TO RENDER HIM/HER UNFIT FOR
SERVICE AT SEA 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 IS TO CERTIFY THAT A PHYSICAL EXAMINATION WAS GIVEN TO:

NAME OF APPLICANT
THIS APPLICANT IS CERTIFIED FREE OF COMMUNICABLE DISEASE: YES NO
CIRCLE APPROPRIATE CHOICE: (HE / SHE) IS FOUND TO BE (FIT / NOT FIT) FOR DUTY AS A (MASTER / DECK OFFICER / ENGINEERING
OFFICER / RADIO OFFICER / RATING) (WITHOUT ANY / WITH THE FOLLOWING) RESTRICTIONS:
NAME AND DEGREE OF PHYSICIAN
ADDRESS
NAME OF PHYSICIAN'S CERTIFICATING
DATE OF ISSUE OF PHYSICIAN'S CERTIFICATE

SIGNATURE OF PHYSICIAN
DATE
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 and the Maritime Labor Convention, 2006.
Rev. 12/09