Medical Examination Report
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4MEDICAL EXAMINATION REPORT
PRIVACY NOTE
The Australian Maritime Safety Authority (AMSA) is collecting the
information on this form for the purpose of assessing your medical
PART A - TO BE COMPLETED BY APPLICANT
fitness for duty at sea and for AMSA audit purposes. The collection of the
You should complete this section before you go for your medical
information is required, authorised or directly related to the Navigation
examination.
Act 2012 (the Act) and the Marine Orders made under it. It will be used
for purposes related to the Act and Marine Orders and will be treated
You must take a suitable means of identification (passport,
in accordance with the Australian Privacy Principles. This information
Australian driving licence) with you to the examination.
may be exchanged between AMSA, your examining medical officer,
Name
your treating medical practitioner and/or any medical panel convened to
assess your fitness for duty at sea. Failure to provide the information may
Family name
result in the transaction not being processed. To contact us, or for more
information on how to access or correct your personal information, how
Given name(s)
to make a privacy complaint, or how your information may be used or
disclosed, visit AMSA’s privacy policy at
Date of birth
Seafarer I.D.
Have you ever had any surgical or chiropractic treatment?
Male
/
/
dd
mm
yyyy
Yes
No
Female
If yes, give details
Indeterminate
Permanent address
Are you taking any medications at present?
Yes
No
Email
Do you have or have you had any eye disorder or injury?
Phone
Yes
No
NOTE: If you wear glasses, corneal or contact lenses, bring them
with you to the examination. CHROMAGEN LENSES MUST NOT
Department/Position on board vessel
BE WORN
Deck Officer (Coastal Pilot / Master / Chief Mate / Mate /
Watchkeeper Deck)
Have you ever been declared unfit for duty at sea?
Engineering Officer (Engineering* / Engineer Watchkeeper*
Yes
No
/ Electro-Technical Officer*)
If yes, state when, for how long and for what reason
Integrated Rating* (Chief / Integrated Rating*)
Rating-Deck (Rating - Navigational Watch / Able Seafarer -
Deck)
Rating-Engineering* (Rating - Engine Room Watch* / Able
Seafarer - Engine*)
Catering (Marine Cook)*
Other (specify)
* Denotes Hepatitis A arrangements apply
Has your Certificate of Medical Fitness ever been restricted or
cancelled or have you ever been declared unfit?
Personal history
Yes
No
Are you in good health now?
Yes
No
If yes, give details
Do you drink alcohol?
Yes
No
If yes, how much and how often?
Do you smoke tobacco?
Yes
No
Have you ever been signed off as sick or repatriated from a ship?
If no, have you smoked in the past?
Yes
No
Yes
No
If yes, give details
Have you been absent from work due to sickness or injury for
more than 14 consecutive days over past two years?
Yes
No
If yes, give details
AMSA 232 (6/16) 1 of 4
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Parent category: Medical