Form Cg-719k - Medical Evaluation Report Page 2
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9Page 2 of 9 of CG-719K Rev. 01-09
General Instructions for Medical Practitioner
1.
The Coast Guard requires a physical examination and certification be completed to ensure that mariners:
►
Are of sound health.
►
Have no physical limitations that would hinder or prevent performance of duties (see below).
Are free from any medical conditions that pose a risk of sudden incapacitation, which would affect operating, or
►
working on vessels.
2.
The medical practitioner must ensure a complete history and physical are conducted and make recommendations as
to the fitness of the applicant. Final approval of the mariner’s status rests with the U.S. Coast Guard.
3.
All examinations, tests and demonstrations must be performed, witnessed or reviewed by a physician (Medical
Doctor (MD) or Doctor of Osteopathy (DO)) or nurse practitioner or a certified physician assistant licensed by a State
in the U.S., a U.S. possession, or a U.S. territory. The verifying medical practitioner (VMP) who performed the
examination must complete sections III, IV, VII, VIII, and IX of this form.
4.
Detailed guidelines on medical conditions subject to further review are contained in NVIC 4-08 encl (3). Medical
practitioners should be familiar with the guidelines contained within this document. NVIC 4-08 may be obtained from
or by calling the nearest USCG Regional Examination Center, or
the National Maritime Center ( ) at 1-888-IASKNMC (1-888-427-5662).
5.
Verification of medications in section III of this form includes questioning the applicant about any medications or
other substances reported, reviewing relevant medical conditions to determine if the applicant has omitted any
medications or other substances, and affirmatively reporting any omitted current medications or other substances
where required.
6.
All applicants who require a general medical examination must be physically examined by the verifying medical
practitioner.
7.
The verifying medical practitioner is not required to perform or witness every examination, test or demonstration.
These may be referred to other qualified practitioners; however, they must be reviewed to the satisfaction of the
verifying medical practitioner. The last page of this form contains a certification that the general medical
examination, vision and hearing tests, as well as the physical demonstration of competence as appropriate, have
been performed, witnessed or reviewed to the satisfaction of the verifying medical practitioner. Applicants who are
required to complete a general medical examination are also required to complete vision tests, and they may be
required to complete hearing tests and/or demonstrations of physical competence as appropriate. The verifying
medical practitioner must sign and date the certification where indicated. This signature attests, subject to criminal
prosecution under 18 USC § 1001, that all information reported by the verifying medical practitioner is true and
correct to the best of his/her knowledge and that the verifying medical practitioner has not knowingly omitted or
falsified any material information relevant to this form.
8.
If the verifying medical practitioner is unable to determine the applicant’s physical ability, the applicant should be
referred to another healthcare provider who can properly evaluate and test physical abilities.
Instructions for Providing Proof of Identity
►
Applicants shall present acceptable proof of identity to the medical practitioner conducting examinations.
►
Medical practitioners must verify the identity of applicants before conducting examinations.
►
Proof of identity
shall consist of one current form of valid government issued photo identification.
►
The following credentials are examples of acceptable proof of identity:
Unexpired official identification issued by a federal, State, or local government or by a territory or possession of the
United States, such as a passport, U.S. driver’s license, U.S. military ID card or Merchant Mariner’s
Document/Merchant Mariner Credential.
Applicant Name: _______________________________________
Date of Birth:____________________________
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