Flight Crew Medical Screening Form printable pdf download

Flight Crew Medical Screening Form

UNITED STATES COAST GUARD AUXILIARY

AVIATION PROGRAM

FLIGHT CREW

MEDICAL SCREENING

FORM

Date of Examination______________

Applicant Name____________________________________________

Auxiliary Number_________________

DOB___________________

AFTER COMPLETION OF THE MEDICAL SCREENING PLEASE

FORWARD THE COMPLETED FORM AS DIRECTED

Note to the physician:

This member of the US Coast Guard Auxiliary has come to you for an evaluation of

basic health and condition, with specific information sought in certain areas which have

a direct applicability to the member’s potential performance and safety during the

conduct of missions.

In addition to the data requested on the form, your judgment is sought regarding the

member’s ability to tolerate long flights (3 to 5 hours duration) in small aircraft and their

ability to successfully egress from the aircraft and swim to a raft in the event of an

emergency. Members must be capable of completing an annual drill in which they must

swim 75 yards fully clothed and then climb into a raft.

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FOUO When Filled In

ANSC 7042A

Revised MAY 10

Flight Crew Medical Screening Form