Seafarer'S Medical Examination Report/certificate Page 2
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3THIS IS TO CERTIFY THAT A PHYSICAL EXAMINATION WAS GIVEN TO:
NAME OF APPLICANT
YES
NO
THIS APPLICANT IS CERTIFIED FREE OF COMMUNICABLE DISEASE:
YES
NO
HEARING MEETS THE STANDARDS IN SECTION A – I/9:
YES
NO
UNAIDED HEARING SATISFACTORY:
YES
NO
VISUAL ACUITY MEETS STANDARDS IN SECTION A – I/9:
YES
NO
COLOUR VISION MEETS STANDARDS IN SECTION A – I/9:
TICK APPROPRIATE CHOICE: HE / SHE IS FOUND TO BE FIT / NOT FIT FOR DUTY AS A MASTER / DECK
OFFICER / ENGINEERING OFFICER / RADIO OFFICER / ELECTRICAL ENGINEER (ELECTRICIAN) / RATING
WITHOUT ANY / WITH THE FOLLOWING RESTRICTIONS:
NAME AND DEGREE OF PHYSICIAN:
ADDRESS OF MEDICAL CENTER:
NAME OF PHYSICIAN’S CERTIFICATING AUTHORITY:
DATE OF ISSUE OF PHYSICIAN’S CERTIFICATE:
SIGNATURE OF PHYSICIAN:
DATE OF EXAMINATION:
EXPIRY DATE OF CERTIFICATE:
SEAFARER ACKNOWLEDGMENT:
I,
(NAME OF SEAFARER), CONFIRM THAT I HAVE BEEN INFORMED
OF THE CONTENT OF CERTIFICATE AND THE RIGHT TO GET A REVIEW.
Page 2
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