DRAFT Merchant Shipping Notice No.

00 of 2013 No: 70-NT (1)/2008-pt Date: 11/07/2013

Sub: Medical Fitness Examinations for Seafarers under STCW, 1995 as amended (2010 amendments) and Maritime Labour Convention [MLC], 2006-regarding. For the attention of: Seafarers, Approved Training Institutes, Ship Owners, Ship Managers, DGS RPS License holders, Seafarers Unions, DGS approved Medical Examiners and Examination Centers and Mercantile Marine Departments, etc. Introduction 1. The Directorate vide its Merchant Shipping Notice No. 23 of 2010 dated 4th November, 2010 developed procedures to grant approval to Medical Examiners for the purpose of conducting Pre-sea (new entrant) and Periodical Medical Examination (existing seafarers). 2. India being signatory to STCW, 1995 as amended and Maritime Labour Convention, 2006 has obligations to implement and enforce its provisions. 2000. 3. The new draft rules conforms to the relevant provisions of STCW, 1995 as amended in 2010, Maritime Labour Convention 2006 as adopted by IMO & IMO/ILO/JMS/2011 including all annexes relating to revised guidelines on the conduct of medical examination. These draft rules shall replace the existing M.S. Medical Examination Rules, 2000 after due promulgation by the Govt. of India. 4. The promulgation of these rules shall be undertaken as per the requirements stated under Section 458 of the Merchant Shipping Act, 1958 that may take some time. In the interim, to give affect to the provisions of STCW, 2010 (amendments) and MLC, 2006 relating to medical examination of seafarers, this M.S. Notice is being issued which supersedes M.S. Notice No. 23 of 2010. This M.S. Notice primarily incorporates the salient features of new draft medical examination rules. In view of this, the Directorate in consultation with the stakeholders has revised the existing M.S. Medical Examination Rules,

Applicability: 5. This notice is applicable to the; 5.1 5.2 new entrant(s) seeking marine profession; seafarers taking certificate of competency / proficiency examination and seeking relevant endorsements under STCW Rules as amended for the purpose of statutory safe manning and other matters incidental to this. 5.3. Seafarers being employed on board ships. Procedure for the approval of medical examiners: 6. Medical examiners seeking approval shall6.1. send an application duly completed in the prescribed format as per Schedule I by post/speed post to the Directorate General of Shipping, Mumbai; 6.2. be a licensed physician and holding at least MBBS degree recognized by the Medical Council of the Central/State Government and his/her age not to exceed 65 years from the date of submission of application; 6.3. 6.4. be experienced in conducting medical fitness examination of seafarer. have the requisite medical facilities and equipments to carry out medical fitness examination, which are conveniently situated for easy access by seafarers, and enabling all the requirements of medical fitness examination to be met and conducted with respect for confidentiality, modesty and cleanliness at the declared premises within the municipal limits of the city. Such declaration shall be made in the check list as prescribed in schedule III; 6.5. be familiar with the relevant sections of the Maritime Labor Convention 2006 adopted by ILO such as Regulation 1.2Medical Certificate, Regulation 3.1Accommodation and recreational facilities and Regulation 4.1 Medical care on board ship and ashore; 6.6. be familiar with the relevant sections of the STCW Convention and the Codes such as Regulation I/9 Medical standards, section

A-I/9-Medical standards, section B-I/9-Medical examination and Certification and Resolution 8- Development of guidelines to implement seafarers; 6.7. be familiar with the latest edition of the International Maritime Guide for ships or an equivalent medical guide for use on ships; possess adequate knowledge of living and working conditions on board a merchant ships or vessels, or other description of vessels use in navigation and the job demands on seafarers in so far as they relate to the effect of health problems on fitness for work. 6.8. this knowledge or may courses be gained either to through special instructions suo-motu relating occupational/maritime medicines conducted by the medical professional bodies in India or otherwise duly approved by the medical professional bodies in India or through adequate shipboard service onboard sea going ships in the capacity of medical doctor or as supernumerary or serving as medical doctor in any shipping company or being associated with the approved Medical examiner of the DG Shipping for adequate period ( preferably at least 6 months ) whichever is practical and convenient to him 6.9. submit along with the application an affidavit confirming the, means used in acquiring the understanding of knowledge of ship board activities, in the prescribed form as in Schedule I-A; 6.10. be well conversant with at least Hindi or English language; 6.11. states that he/she enjoys full professional independence in exercising their medical judgment when undertaking medical examination procedures; and 6.12. submit all supporting documents duly notarized or attested by the Gazette officer or self attested. 6.13. the Medical practitioner shall be personally interviewed by the duly designated officer of the Directorate General of Shipping. The duly designated officer may carry out the inspection of his / international standards of medical fitness for

her premises to verify the facilities at the Diagnostic Laboratory or other premises. 6.14. upon receipt of satisfactory compliance report along with the applicable documentary evidences confirming the compliance and fulfilment of to administrative approve, the procedures Directorate and clear of recommendations General

Shipping shall approve the Medical practitioner. the prescribed format as

The Medical This

Practitioner thereafter shall be issued with letter of approval in specified in Schedule-II . approval shall be valid for empanelled Medical examiners for till the validity of his current registration or maximum period of 5 years. 6.15. the empanelled Medical examiners, the approval to these may be extended for further till the validity of his current registration or maximum period of 5 years may renew their empanelment within 6 months of date of coming into force of these rules. 6.16. such medical examiners who attains age of 65 years, may apply for the extension to the Approving Authority in the prescribed format as specified in Schedule I. The Directorate General of Shipping may in such cases extend the letter of approval for a period of maximum 5 years up to a maximum age of 75 years as prescribed in schedule II. 6.17. No further extension shall be considered for medical examiners above 75 years of age. all approved Medical examiners shall be placed on the panel of the DGS. Their names along with contact details shall be disseminated through the DGS website as soon as possible. 6.18. all approved Medical examiners, who are on the panel of the DGS shall submit 6 monthly returns in the prescribed format as specified in Schedule VIII in electronic form and followed by hard copies. Changes in the status of the approved Medical examiner in terms of his/her medical fitness, place of business, number of facilities and sub contracting of related services if undertaken or any other reasons shall be communicated by the Medical

examiner to the Directorate General of Shipping within 30 days of such schedule through normal postal service. Types of Medical Examination7. The approved Medical examiner as per the request of the

company, approved training institute, new entrant, seafarer or person as case may be shall conduct the following types of medical examination 7.1. a pre sea medical examination-this examination provides an opportunity to prevent entry of unsuitable new entrant to the seafaring profession for health reasons apparent at that time. This examination shall therefore be more stringent in nature than the periodic medical examination. 7.2. a periodic medical examination -this examination provides an opportunity to ensure that seafarer or person remains fit for sea service by identifying medical conditions which may have develop since the seafarer entered the profession. It shall be more flexible than the pre sea examination, yet not so flexible as to permit unfit seafarer to work at sea or resume ship board duty or undergo certificate of competency and related examinations and obtain applicable endorsements. Frequency of medical examination: 8. Medical Examinations are normally performed every two years. Where there is a health condition that requires more frequent surveillance, they may be performed at shorter intervals. It is important to recognize that the requirement for more frequent medical examinations may limit the ability of a seafarer to obtain employment and lead to additional costs for the seafarer or their employer. If medical examinations are at intervals of less than two years, they may solely concern the condition under surveillance and, in this case, any reissued medical certificate shall not be valid for more than two years from the previous full examination; 9. Any medical examination at the request of employer or training institute or the seafarer shall be conducted in accordance with

this notice.

A medical certificate shall be issued by the

approved medical examiner to the seafarer who meets all requirements with regard to medical fitness as prescribed under the provision of M.S. Act, 1958 as amended, MLC, 2006 as amended and STCW, 1978 as amended. This medial certificate shall be issued in prescribed format in schedule-VII only on the basis of compliance with statutory standards irrespective of compliance requirements. 10. Seafarer medical examinations may also provide an opportunity to take measures to correct or mitigate medical conditions which could adversely affect the health of seafarers and shall include measures of a preventive character. Tests necessary to evaluate the occupational exposure at work on board ship may, when appropriate, be performed at the same time as the periodic examinations. Conduct of Medical Examination by the Approved Medical examiner: 11. The approved Medical examiner and the associated laboratory shall conduct the physical, mental tests as per the relevant provisions of these rules and shall use prudence and professional medical judgments and experience. Medical Fitness Standards- Verification: 12. The medical examiner in assessing the medical fitness of seafarers including new entrant shall take into account the physical capability requirement, fitness criteria for medication use, medication that can impair routine and emergency duties and medication that can have serious adverse consequences for the user while at sea including medications that require limitations of period at sea because of surveillance requirements. In doing so the medical examiner shall taken into account the guidelines specified in ILO/IMO publication Guidelines on the medical examination of seafarersILO/IMO/JMS/2011/12. seafarers; 12.1. Appendix A- Vision standards - STCW Code table A-I/9: Minimum inThe medical examiner shall pay special attention to the following as far as the examination and issuance certification of with any additional employer or insurer

service eyesight standards for seafarers 12.2. Appendix B- Hearing standards testing as per the prescribed procedure and criteria 12.3. Appendix C- Physical capability requirements - Table B-I/9. Assessment of minimum entry level and in-service physical abilities for seafarers. 12.4. Appendix D-Fitness criteria for medication use as prescribed. 12.5. Appendix E- Fitness criteria for common medical conditions as prescribed -

Validity of Medical Examination Certificate: 13. Unless a shorter period is required by reasons of the specific duties/functions to be performed by the new entrant, seafarers and persons concerned, the validity of the medical certificate shall be as follows: 13.1. the medical certificate shall be valid for a maximum period of 2 years and colour vision certificate for maximum period of 6 years. However, frequent test that may include eye sight test & other applicable tests as is deemed necessary by the Approved Medical examiner may be carried out; 13.2. unless the new entrant, seafarer or person is under age of 18, in which case the maximum period of validity shall be 1 year. However, frequent test that may include eye sight test & other applicable tests as is deemed necessary by the Approved Medical examiner; and 13.3. every seafarer signing off from the ship on medical grounds for whatsoever reasons shall be subjected to fresh periodic medical examination even if, the existing medical certificate held by him/her is valid.; 13.4. every seafarer shall be subjected to physical examination which

may inter-alia include examination of organ or organ systems such as; 13.4.1. head, eyes, ears, nose, mouth, throat, neck, chest, abdomen, skin and limbs etc. 7

13.4.2. 13.4.3. 13.4.4.

vital signs - blood pressure, pulse rate and body temperature etc; vital Systemsrespiratory, cardiovascular, nervous, gastrointestinal and genitourinary etc; general appearance- posture, expression, restlessness, speech, behaviour and sweating including weight and height etc; and

13.4.5.

if deemed necessary clinical tests based on the declaration made by the seafarer before the approved medical examiner or requested by the company as the case may be.

13.4.6.

the medical certificate for new entrant, seafarers or persons shall as a minimum be provided in English.

13.5. The medical examiner shall assess the physical and mental condition of the applicant and conduct the relevant clinical test as prescribed in schedule-V. The medical examiner may as per his professional medical judgment in addition carry-out additional test taking into account the medical declaration made by the seafarers as prescribed in schedule -VI and other factors as deem fit for the specific case. 13.6. The seafarer shall not suppress medical information and declare correct and proper medical information to the medical examiner to the best of his knowledge and belief.

In case of any

wrongful Act or misrepresentation/suppression of material fact(s) of information or infringement the concerned seafarer shall be fully responsible/liable for the consequences/ damages / penalties as per the provisions or the applicable laws.
Appeal Procedures 14. Any applicant whose case has been rejected by the Directorate

General of Shipping for the approval to perform the functions of Medical Examiner or extension of approval, suspension or withdrawal or a ship-owner not accepting the decision of approve medical examiner or seafarer having

grievance against approved medical examiners or ship-owner may lodge an appeal within three months from the date of issue of such decision. Such appeal shall be made to the Director General of Shipping & accompanied by a copy of the order appealed against in writing including contents of any rejection; 14.2. on receipt of the appeal the Director General of Shipping shall examine the case and may give the applicant a reasonable opportunity of being heard before disposing the case. 14.3. an appeal shall be disposed within a period of sixty days from the date of filing of the appeal; 14.4. the Director General of Shipping may confirm, modify or reverse the order, appealed against. 15. Compliance and Enforcements : 15.1. All concerned in order to give affect to the provision of MLC, 2006 and STCW, 2010 in respect of medical examination of seafarers are advised to comply with this notice and insure that the medical certificate prepared and issued which is based on medical examination seafarers declaration. The medical certificate for the new entrant and existing seafarers before they embarked on board your ships are issued which conforms to the provisions of STCW, 2010, MLC, 2006 and IMO/ILO/JMS/2011 revised guidelines of conduct of medical examination. 15.2. As regards, the trainees or seafarers already in employment of ship-owners or ship manager or RPS license holders and serving on board Indian Flag Ships, the medical certificate issued under the existing Medical Examination Rules, 2000 shall remain valid wherever the Indian ship is. In the event of expiry of such certificates at sea, it shall remain valid till arrival of next port of call or where the facility of medical examination is available. 15.3. The ship-owners, ship managers and RPS license holder of the Directorate as the case may be shall advise their empanelled medical examiners who are approve by D.G. Shipping to be guided by this notice. 15.4. All concerned in order to avert any intervention by the Port State Control Authorities or Flag State Control Authorities or delegated

authorities of the flag state to voluntarily comply with this requirement from the date of issuance of this notice. 15.5. MLC, 2006, is entering into force internationally w.e.f. 20/08/2013 and therefore it is essential that all concerned shall comply with the provisions of this notice strictly. However, ship owners or managers or RPS license holders may issue medical certificate or voluntary basis prior to this. 15.6. This notice shall comes w.e.f. ............ and may be reviewed if deemed necessary at periodical interval. 15.7. These issues with the approval of Director General of Shipping.

(Capt. Deepak Kapoor) Deputy Nautical Advisor -cumSr. Deputy Director General DDG (Tech) List of Annexes Schedule I- Application for Approval and Extension of Approval Schedule II- Affidavit format Schedule III- Letter of Approval/Extension of Approval to the Medical examiner Schedule IV- Check List for Approval /Extension of Approval to the Medical Examiner Schedule V - Minimum Test for the conduct of medical examination Schedule VI Medical Examination of Seafarer (Examinees Declaration). Schedule VII- Medical Certificate to Seafarer Schedule VIII Half Yearly Returns

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Schedule I Application for Approval and extension of Approval

Photograph (size)e 3.5 3.5 To Directorate General of Shipping _________________ Date

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Jahaz Bhavan, ________________ Walchand Hirachand Marg, Ballard Estate, Mumbai-400 001.

Place

[Kind Attn: Approving Authority (Nautical Adviser to the Government of India) ]. [Subject:- Approval / Extension of approval to Medical examiner -regarding.] Sir, I, Dr. examination. __________________________________ wish to apply for the approval of Medical examiner / extension of approval to conduct medical A copy of my Bio-data along with other relevant documents pertaining to academic and professional qualification, experience, previous letter of approval, proof of age, check list duly notarized or certified and filled in are enclosed. I declare to extend all co-operation to the authorized official of the Competent Authority in course of interview and inspection of premises before the approval or thereafter. You are therefore, requested to issue a letter of approval / extension of approval to enable me to perform the function of Medical examiner for the purpose of medical examination. Yours faithfully,

(Dr._____________________) Name:__________________ Medical Council of India Registration No.__________ Date of issue: __________________ (delete as applicable) Enclosures: 1. Copy of Medical Council of India Registration Certificate.

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2. 3. 4. 5.

Copy of bio-data with supporting documents including an affidavit Copy of check list duly filled in with relevant information. Copy of proof of age. Copy of previous letter of approval, if applicable. [Note:Gazette officer or self attested] A copy of above mentioned documents shall be duly notarized or certified by

6. 7. 8. 9.

A proof for medical fitness by Government department in case of extension. A proof for filing periodical returns in case of extension. A proof stating no pending complaints or legal proceedings for new applicant and existing cases. Two passport size photograph (3.5 x 4.5 cm)

Schedule II AFFIDAVIT I, Dr. ______________, Regn. No. ______, (State/Centre) Medical Council, aged ____ years, Indian Resident, having my clinic at ______________, do hereby on solemn affirmation as under: 1. I am fully conversant with the applicable Indian Maritime Laws, the entire process of examination the seafarers and good understanding in the following areas: (i) have adequate knowledge of living and working conditions on board sea going merchant ships of various types gained through special instructions or attended occupational/Maritime medicine/health related courses or other means as prescribed by the council or association or self efforts.

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(ii) (iii) (iv) (v)

(vi) (vii)

(viii)

Medical publication The International Medical guide for ships or an equivalent national medical guide for use on ships. Standard of Training, Certification and Watchkeeping 1995 as amended REG I/9-Medical Examination. Maritime Labour Convention 2006- Medical Examination of Seafarers. International Labour Organization/World Health Organization/D.2/1997, as amended-Guidelines for conducting pre-sea and periodic medical fitness examination of seafarers. Relevant provisions of Merchant Shipping Act, 1958, section 98 etc. Merchant Shipping (Medical Examination) Rules 2000, as amended and DGS/M.S. Notices of Medical Examination and Sight test issued from time to time as available on DGS website. Procedure to deal with appeal cases etc.

I state that the contents of this affidavit are true and correct to my knowledge. Solemnly affirmed in _______ on dd/mm/yyyy (place) Before me Attested

Schedule III Letter of Approval / Extension of Approval (No.DGS/Medical/_______) Reference No. --------To, Dr [Sub: Letter of Approval / extension of approval to Dr. Registration No. --- ] -----------------------------------------------------------------------------------------------Sir,

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In response to your application No.__________

dated

and

subsequently fulfilling the laid down criteria for the approval /extension of approval], the Competent Authority is pleased to accord approval or extend approval to you as Medical examiner in accordance with Section 98 (4) of Merchant Shipping Act, 1958. [You are therefore permitted to conduct medical examination in accordance with the relevant provisions of Merchant Shipping Act, 1958, Rules framed their under and other laws applicable, including any notification issued by Competent Authority from time to time. Your name along with contact details given by you in the application / check list shall be displayed on the DGS Website at the earliest. with the following conditions. 1. 2. 3. The Nautical Advisor to the Government of India has the right to suspend or withdraw this letter of approval / extension or report to the concerned authorities after giving an opportunity to you to defend. However, you have the right to appeal to the Competent Authority against such decision. Yours faithfully, (Authorized Official of Competent Authority) (delete as applicable) Cc: 1. All Principals Officers, MMD Schedule IV CHECK LIST FOR APPROVAL/EXTENTION OF APPROVAL TO MEDICAL EXAMINER (To be duly filled in by the applicant) PART A Name of the applicantDate of birthName & address of clinic at which medical examination to be conducted PART B This approval shall remain valid for --- years till ----------- subject to the compliance

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Educational qualification with certified copies as attachmentProfessional qualification with certified copies as attachment (at least M.B.B.S.)IMC registration numberDetails of experience including experience on ships or in lieu adequate knowledge on living and working condition on board merchant ships Details of qualified support staff having adequate experience in providing medical services to the seafarersDetails of other doctors, managerial, Para-medical and clerical staff including consultantsDetails of the clinic(numbers) and laboratory facilities(numbers) adequate area to accommodate medicals officer, staff, record room, waiting area for seafarers & list of medical examination facilities at the clinic List of clients giving evidence of integrity, goodwill and understanding of seafaring profession -

Names of inspecting team 1. 2. 3.

Remarks of the Inspecting TeamRecommendations of the Inspecting team-

Date

Official Seal

Place

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Schedule V Minimum Test for the conduct of medical examination

1. Periodic Medical Examination (Sea Service & Certification purposes) (A) Mandatory Examination and Tests (Sea Service) Physical Examination: Weight, Height, Temperatures, Blood Pressure, pulse rate, Sight, Hearing , Oral Health ,general appearance and systemic examination of whole body. Blood Tests :17

BI CBC BI ESR RBS / FBS SGOT SGPT SGGT S Creatinine & Urea S Cholesterol S Triglycerides Blood group & Rh factor( tested only once, need not be repeated) Test for Hepatitis B (HbsAg) and C VDRL HIV I& II X-ray chest Urinalysis ECG Drug & Alcohol Screening Morphine, Barbiturates, Marijuana, Cocaine, Amphetamines, Alcohol Audiometric Stool R/E & Widal for food handlers Ultrasound (USG) of the Abdomen & Pelvis

(B) Optional TestsPsychometric evaluation on case to case basis Stress test 2D echo Doppler study (for heart patient) Glycosylated (Hb1Ac) Spirometry

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3. Mandatory Examination and Tests (Certification of Competency and other endorsements) subject to the candidate not having medical certificate. (i) Physical Examination: Weight, Height, pulse rate, Temperatures, Blood Pressure, Sight, Hearing ,Oral Health ,general appearance and systemic examination of whole body. (ii)Blood Tests :BI CBC BI ESR RBS / FBS SGOT SGPT SGGT S Creatinine S Cholesterol S Triglycerides Blood group & Rh factor Test for Hepatitis B (HbsAg) and C BI VDRL HIV I& II

(iii)X-ray chest (PA) (iv)ECG (v) Urine analysis 4. Pre-sea Medical Examination(New Entrant)(A) Mandatory Examination and Tests

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Physical Examination: Weight, Height, Temperatures, pulse rate, Blood Pressure, Sight ,Hearing , Oral Health , general appearance & systemic examination of the whole body . Blood Tests :BI CBC BI ESR SGOT SGPT SGGT S Creatinine S Cholesterol S Triglycerides Blood group & Rh factor CL Test for Hepatitis B (HbsAg) and C BI VDRL HIV I& II X-ray chest (PA) Urinalysis Drug & Alcohol Screening Morphine, Barbiturates, Marijuana, Cocaine, Amphetamines, Alcohol Audiometric Psychometric test conducted by any qualified psychiatrist / psychologist Ultrasound (USG) of the Abdomen & Pelvis (B) Optional TestsGlycosylated (Hb1Ac) RBS/FBS(Blood test) ECG Stress Test if deem necessary 2D echo Doppler study Psychometric evaluation on case to case basis 5. Vaccination under WHO or other countrys regulations as applicable20

(i) Vaccination at the time of Pre-sea and Periodic test:- Seafarers shall be vaccinated according to the requirements indicated in the WHO publication, International Travel & Health; vaccination requirement and health advise updated periodically. (ii) Yellow fever is now only decease for which vaccination is statutory requirement in some countries and for which an International certificate of vaccination is required. Responsibility to provide immunization shall rest with the training institute and the employer of the seafarer as the case may be. Yellow Fever At a WHO designated Yellow Fever Centre only. Booster once every 10 years for seafarer and new entrant. Hepatitis B & C A primary course of three doses to be completed during the training period. Booster may be given once every 20 years. In cases of doubtful immunity, test for Anti HBS antibody titre shall be conducted to assess the suitability of administration of the vaccine. c) Typhoid vaccination - during training & to be repeated once every three years. A primary course of two doses. d) Tetanus Toxoid Most of the pre-sea trainees would have received their tetanus prophylaxis during their childhood immunization. However, tetanus toxoid injection shall be given at the time of entry to the pre-sea training programme. A booster injection every 5 years. e) Hepatitis A Vaccination. f) Vaccination against any other epidemic or pandemic disease at that period of time. 21

(ii) Vaccination at the time of Periodic Medical Examination: Note :The DG approved Medical examiner shall check the immunization record of new entrant or the seafarers as the case may be, at the time of pre-sea or periodic medical examination and arrange for re-vaccination if and when deemed necessary. These records shall be retained with the seafarers and to be verified periodically.

Schedule VI MEDICAL EXAMINATION OF SEAFARERS Examinee's Declaration PS: 1. The seafarer shall not suppress medical information and declare correct and proper medical information to the medical examiner to the best of his knowledge and belief.

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2. In case of any wrongful Act or misrepresentation/suppression of material fact(s) of information or infringement the concerned seafarer shall be fully responsible/liable for the consequences/ damages / penalties as per the provisions or the applicable laws.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Name (last, first, middle): _____________________________________________ Date of birth (day/month/year): .. /.. /. Sex: __ Male __ Female Home address: _______________________________________________________ Method of confirmation of identity, e.g. Passport No./Seafarers book No. or other relevant identity document No.: _____ Department (deck/engine/radio/food handling/other): _____ Routine and emergency duties (if known): _____ Type of ship (e.g. container, tanker, passenger): _____ Trade area (e.g. coastal, tropical, worldwide): _____ Examinees personal declaration

(Assistance should be offered by medical staff)

11.

Have you ever had any of the following conditions? Yes Eye/vision problem High blood pressure Heart/vascular disease Heart surgery Varicose veins/piles Asthma/bronchitis Blood disorder Diabetes Thyroid problem Digestive disorder Kidney problem Skin problem No

Condition

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Allergies Infectious/contagious diseases Hernia Genital disorder Pregnancy Sleep problem Do you smoke, use alcohol or drugs? Operation/surgery Epilepsy/seizure Dizziness/fainting Loss of consciousness Psychiatric problems Depression Attempted suicide Loss of memory Balance problem Severe headaches Ear (hearing, tinnitus)/nose/throat problem Restricted mobility Back or joint problem Amputation Fractures/dislocations

If you answered yes to any of the above questions, please give details:

12. Additional questions Have you ever been signed off as sick or repatriated from a ship? Have you ever been hospitalized? Have you ever been declared unfit for sea duty? Has your medical certificate even been restricted or revoked?

Yes

No

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Are you aware that you have any medical problems, diseases or illnesses? Do you feel healthy and fit to perform the duties of your designated position/occupation? Are you allergic to any medication?

Comments:

13. Additional questions Are you taking any non-prescription or prescription medications?

Yes

No

If yes, please list the medications taken, and the purpose(s) and dosage(s): I hereby certify that the personal declaration above is a true statement to the best of my knowledge. Signature of examinee: _______________________Date (day/month/year): ../../. Witnessed by (signature): ___________ Name (typed or printed): _________________ I hereby authorize the release of all my previous medical records from any health professionals, health institutions and public authorities to Dr ______________________ (the approved medical practitioner). Signature of examinee: _______________________ Date (day/month/year): ../../. Witnessed by (signature): ___________ Name (typed or printed): _________________ Date and contact details for previous medical examination (if known): _________ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------14. MEDICAL EXAMINATION Sight

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Use of glasses or contact lenses: Yes/No (if yes, specify which type and for what purpose) ___________________________________________________________________________ Visual acuity

___________________________________________________________________________ Unaided Right eye Distant Near ___________________________________________________________________________ Visual fields __________________________________________________________________________ Normal Defective _______________________________________________________________________ _ Right eye Left eye ___________________________________________________________________________ Colour vision Not tested Defective Hearing Normal Doubtful Left eye Binocular Aided Right eye Left eye Binocular

___________________________________________________________________________

___________________________________________________________________________ Pure tone and audiometry (threshold values in dB) ___________________________________________________________________________ 500 HZ 1 000 HZ 2 000 HZ 3 000 HZ ______________________________________________________________________________ Right ear Left ear ______________________________________________________________________________ Speech and whisper test (metres) ______________________________________________________________________________ Normal Whisper ______________________________________________________________________________ Right ear Left ear ______________________________________________________________________________

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15.

Clinical findings

Height: _____ (cm) Weight: _____ (kg) Pulse rate: _____/(minute) Rhythm: _____ Blood pressure: Systolic: _____ (mm Hg) Diastolic: _____ (mm Hg) Urinalysis: Glucose: _____ Protein: _____ Blood: _____ ______________________________________________________________________________ Normal Head Sinuses, nose, throat Mouth/teeth Ears (general) Tympanic membrane Eyes Ophthalmoscopy Pupils Eye movement Lungs and chest Breast examination Heart Skin Varicose veins Vascular (inc. pedal pulses) Abdomen and viscera Hernia Anus (not rectal exam) G-U system Upper and lower extremities Spine (C/S, T/S and L/S) Neurologic (full/brief) Psychiatric General appearance 16. Chest X-ray Not performed Performed on (day/month/year): ../../. Abnormal ______________________________________________________________________________

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Results: 17. Other diagnostic test(s) and result(s): Test: Result:

Medical practitioners comments and assessment of fitness, with reasons for any limitations: 18. Assessment of fitness for service at sea On the basis of the examinees personal declaration, my clinical examination and the diagnostic test results recorded above, I declare the examinee medically: Fit for look-out duty Not fit for look-out duty Other services (training/examination) Deck service services Fit Unfit No Describe restrictions (e.g., specific position, type of ship, trade area & others as applicable): Medical certificates date of expiration (day/month/year): ______/______/______ Date medical certificate issued (day/month/year): Number Signature of of approved medical medical ________________________________________________ examiner: _____________________________________ Approved Medical examiner information (name, license number, approval number, address): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______/______/______ certificate: Yes Engine service Catering service Other

Without restrictions with restrictions Visual aid required

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Schedule VII MEDICAL CERTIFICATE FOR PRE-SE-TRAINING- CERTIFICATE OF COMPETENCY / PERIODIC MEDICAL EXAMINATION SERVICE AT SEA As per medical standards of MLC 2006, as amended STCW 2010, as amended and section 98 of the Indian Merchant Shipping Act, 1958 and medical examination rules on medical examination framed there under

APPROVED MEDICAL EXAMINER NAME AND ADDRESS

Last/Family Name Position applied for Date of Birth Company Name Sex

First Name ID (Passport/Discharge book) No:

Photo
Nationality Vessel Name

I have evaluated the above-named seafarer/ new entrant after establishing his identity as per the documents mentioned above. On the basis of the seafarers/ new entrant personal declaration, my clinical examination, the diagnostic test results obtained, and in consideration of the essential requirements of the position applied for, my opinion is (a) (b) (c) that the hearing meets the required STCW standards section A-I/9:Yes / No Unaided hearing is satisfactory Yes / No Visual acuity meets the required STCW Code standards section A-I/9 Yes / No

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(d)

Color Vision meets the required STCW Code standards section A-I/9 Yes / No (testing only required every 6 years unless considered necessary ) Date of last color vision test ( Day/Month/Year) (a) Fit for look out duty (b) No. limitation or restrictions on fitness .. Yes / No Yes / No

(e)

(if no specify limitations or restrictions (c) Is the seafarer free from any medical condition likely to be aggravated by Service at sea or to render the seafarer unfit for such service or to endanger the health of other persons on board : Yes / No (d) Date of examination: (Day/Month/Year) (e) Expiry date of certificate: (Day/Month/Year)

(f)

this seafarer is UNFIT FOR DUTY**/FIT FOR DUTY with / without restrictions*as mentioned below, * This Medical Certificate is issued with following restrictions

** Reasons for being unfit

Approved Medical Examiner Signature::_______________________ Official Stamp (Registration No. & DGS approval no.) Approved Medical Examiner Name Printed:___________________________ Date : Valid till:

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Approving Authority of Medical Examiner: Directorate General of Shipping, Govt. of India.

I acknowledge, that I have been advised of the content of the medical certificate & of the right to a review in accordance with paragraph (6) of section A-I/9 of STCW Code. Seafarers/ New Entrant Signature:

Schedule VIII Half Yearly Returns Format SUMMARY OF MEDICAL EXAMINATION CONDUCTED FOR THE PERIOD FROM ------------ TO ---------Sr. No . Name of the seafarer Date of Birth/Ran k Male / Femal e CD C No. Pre sea / Periodic or additional examinati on Name of shipping Compan y /training institute Unfit / Tempora ry Permane nt If unfit reason( s) for unfitnes s If referred to Authorit y

Signature of the Medical examiner:Name of the Medical examiner:Registration No. :DGS approval number:******

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