As Per Merchant Shipping (Medical Examination) Rules, 2010 & Ism/Stcwcode /9 and MLC Convention 2006 (A Rhha 2
As Per Merchant Shipping (Medical Examination) Rules, 2010 & Ism/Stcwcode /9 and MLC Convention 2006 (A Rhha 2
As Per Merchant Shipping (Medical Examination) Rules, 2010 & Ism/Stcwcode /9 and MLC Convention 2006 (A Rhha 2
Company Name
MEDICAL HISTORY Please answer the following to the best of your knowledge.
Is there any past present history Candidates Examiners
Record
Candidates Examiners
of any of these Declaration Declaration
Yes No Yes No Yes No Yes No
Severe one-sided headache (Migraine) No
No Hernia/ Hydrocele I Appendicitis NO No
Jaundice/Liver Disease NO
No Diabetes No No
Piles /Varicose Veins No No Nervous / Mental illness No No
l2 Healthy
Distant Vision |Uncorrected Corrected | Hearing Normal Voice
Whispered Voice
Right Eye 6lc Right Ear Normal NAD NAD
Colour Vision Normal |Auditometryy kHz 500 1000 2000 3000 4000 5000
Normal dB As per Audiometry Report attached.
Field of Vision Normal |Right Ear
eftEar Normal dB
Notes
ystemic Exam Normal Abnormal Notes Normal Abnormal
| Head & Neck
NAD Respiratory System YES
Eyes NAD Cardiovascular System YES
Ears/Nose/Throat NAD Per Abdomen YES
Teeth/Oral Cavity NAD Genito-urinary system YES
MEDICAL CERTIFICATE
nis certified that the seafarer concerned is not suffering from any medicalconditionlikely to be aggravated by senvice at sea or to
render the seafarer unfit for such service or to endanger the health of other persons onboard.
P-13
Dr. GV. Rao, M.D. (Gen)
Marine Medical Consultant (DG
Sunita Nursing Home,
Shipping Approved)
Visakhapatnam
530 013 -
The cut-off values are based on the recommendations of N.ID.A. & S.A.M.H.K.A. (U.S.A.).
Note: A Positive result indicates only the presence of the metabolite above the cut off value. It
does not indicate or measure intoxication.
The urine analysis for the above are done by any one of the following available assay
methods
IMMUNOMETRIC ASSAY (RAPID-CHROMATOGRAPHY)
FPIA (FLUORESCENE POLARISATION IMUNO ASSAY)
ELISA
RIA (RADIO IMMUNO ASSAY)
Alcohol test is done by cnzymatic method on Auto-analyzer or breath test of saliva test.
and has been found fit for service at sea in the job of
&w20
(Date&Place of Medical Examination)
(Signdture of the Medical Examiner)
RAO
2 8. 2 o 2
Official Stamp of the Medical Examiner
This Certificate expires on *_
(Day, Month, Year)*
of 18, in which case the maximum period of validity of the
unless the seafarers, is under the age
("Not more than 2 years from the date of issue,
Medical Certificate shall be 1 year).
course of voyage, the medical
certificate
medical certificate expires in the
If the period of validity of the Medical Examiner is available and the
the next port of call where an approved
shall continue in force until exceed 3 months.
that period of suchfextension shall not
seafarer can obtain a medical certificate, provided
Appendix - V
Reference No.
Colour of eyes
Identification Notes
Unaided
Distant Vision
Aided
Unaided
Near Vision
Aided
Horizontal Plane N
Field of vision
Vertical Plane N
Ishihara M
Colour Vision
Lantern / others
Medical Examiner
Candidate's Signature
Signature of DG approved and Mates, MMD
or Examiner of Masters
GV. . RAO
Dated 202t 273 D (Gen)
10
1C313
Note:
should be
above date. New entry sight test certificates
This certificate is valid for two years from the
candildate till his active sea career.
retained by the
this application shall
further advise in case of periodical eye
sight test, one copy of
If failed or to be referred for Examiner of Masters and Mates with detailed report.
Marine Department/Chief
be forwarded to the Mercantile
Where not examined indicate by stating N/E. and colour vision only.
candidates to test for distant
Examiner of master and mates will subject
Delete if not applicable