Certificate Of Medical Fitness - Seafarers (Form) - Maritime Nz

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Certificate of Medical Fitness – Seafarers
Please indicate with an X whether this certificate is for an STCW or a national certificate of competency or proficiency:
(
STCW
National
(issued in accordance with STCW regulation I/9
by an approved medical practitioner)
Surname: _______________________________________First name(s): _______________________________________________________
Date of birth (day/month/year): _________/__________/_________
Male
Female
Home address: ______________________________________________________________________________________________________
Identity document type: _________________________________No.: ____________________________Nationality: _____________________
Duties aboard ship
Deck
Engine
Catering
Other (specify): _______________________________________
I have evaluated the above-named examinee in accordance with Maritime Rule Part 34.
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’s medical category under Maritime Rule Part 34.25 (2) is:
(Medical category letter): ____________________
(Medical category explained in text): __________________________________________
Restrictions
Duties:
Location/vessel:
Medical/other:
I can confirm the following: (tick relevant box)
Eyesight:
Meets visual acuity standards
Yes
No
Visual aids (tick if worn) Spectacles
Contact lenses
Meets colour vision standards
Yes
No
Date of last colour vision test:
_____/_____/_____
(Note: colour vision test is not required for national engineering certificates)
Hearing:
Meets hearing standards
Yes
No
Lookout duties (deck department only)
Unaided hearing satisfactory
Yes
No
Fit for lookout duties
Yes
No
The examinee is free from any medical condition likely to be aggravated by service at sea,
Yes
No
render him/her unfit for sea service, or endanger the health of others on board .
Place of examination: _____________________________
Official stamp
(also print name of medical practitioner if not legible)
Date (day/month/year): ______/______/______
Certificate date of expiry (day/month/year): _____/______/_____
Medical practitioner’s signature: _________________________________________MCNZ ID: _______________________________
I acknowledge that I have been advised of the content of the medical examination form.
Examinee’s signature: ________________________________________________________
(signed in the presence of the medical practitioner)

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