Form Cg-719k - Medical Evaluation Report
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9U.S. DEPARTMENT OF
Merchant Mariner Credential
OMB-1625-0040
HOMELAND SECURITY
U.S. COAST GUARD
Expires 6/30/2012
Medical Evaluation Report
CG-719K Rev. (01-09)
• Detailed guidance on the medical and physical evaluation guidelines for merchant mariner credentials is contained in
Navigational and Vessel Inspection Circular (NVIC) 4-08.
• Additional information is also available at the National Maritime Center (NMC) Homeport website at:
• Additional information can also be obtained from NMC at: Commanding Officer, National Maritime Center, 100 Forbes
Drive, Martinsburg, WV 25404 or 1-888-I-ASK-NMC (1-888-427-5662)
Who must submit this form?
►
Applicants seeking an original, renewal or raise-in-grade credential are required to complete this form (if a previous
medical evaluation is not submitted within the past 3 years) and submit it to the U.S. Coast Guard.
►
Guidance for required submission of this form is contained in
Enclosure (1) of NVIC
4-08.
Instructions for Applicants
►
Applicants are required to provide the applicant information in section I, medication information in Section III, and
certification of medical conditions in Section IV.
►
Applicants are required to sign and date the certification in section I of this form attesting, subject to criminal
prosecution under 18 USC § 1001, that all information reported is true and correct to the best of their knowledge and
that they have not knowingly omitted or falsified any material information relevant to this form.
►
Applicants should also complete the release in section II of this form.
Privacy Act Statement
As required by Title 5 United States Code (U.S.C) 552a(e)(3), the following information is provided when supplying
personal information to the United States Coast Guard.
1.
Authority for solicitation of the information: 46 U.S.C. 2104(a), 7101[c]-(e), 7306(a)(4), 7313[c](3), 7317(a),
8703(b), 9102(a)(5).
2.
Principal purposes for which information is used:
a. To determine if an applicant is physically capable of performing their duties.
b. To ensure that a duly licensed or certified Physician (MD or DO) / Physician Assistant / Nurse Practitioner
conducts the applicant’s physical examination/certification and to verify the information as needed.
3.
The routine uses which may be made of this information:
a. This form becomes a part of the applicant's file as documentary evidence that regulatory physical
requirements have been satisfied and that the applicant is physically competent to hold a credential.
b. The information becomes part of the total credential file and is subject to review by Federal agency casualty
investigators.
c. This information may be used by the United States Coast Guard and an Administrative Law Judge in
determining causation of marine casualties and appropriate suspension and revocation action.
4.
Disclosure of this information is voluntary, but failure to provide this information will result in non-issuance of a
credential.
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a valid OMB control number. The United States Coast Guard estimates that the average burden for completing
this form is 20 minutes. You may submit any comments concerning the accuracy of this burden estimate or any
suggestions for reducing the burden to the Commandant (CG-543) United States Coast Guard. 2100 2nd Street SW.
Washington, DC 20593-0001.
Applicant Name: _______________________________________
Date of Birth:____________________________
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