SAMPLE - fol REFERENCE jofartsdirektoratet —Helseerktzering/ uated, icate| oC Norwegian Maritime Authority ‘Serienummer / Serial number HP- [Etter 2. Kjonn / Gender ‘Mann / Mole a 1. Fomavn / First name Kvinne/ Female = [) AdO [a Nasjoalst 7 Notinaly 5 Fodetais pre oh ’ © Peonnummer 7 Watlonl Kent mabe -mamber 7. Shek vio 10 checked a ta vesLO Met / No] (Chey | Rive stant ine fe doce 7 na Worse mater waveneSTGW-Kenversonen ait 1/377 Rearing meets the tandoras in STW Code section RP ta/ves(OP Nelo Biases tenant Ud eo satan? aves OF weno | TL Synet moter Kraven STEW -Lonvensjonen avsnittA-1/8?/ Visual acuity meets standards in STCW Code segtion A-178 Ja/YesEY Nei /WoC] 12. Fargesyn mater kravene i STCW-Konvensjonen avsnitt A-1/5? / Colour meets standards in STCW Code section A-1/9? | Ja/ Yes Nei / oT] 15. Dato for forrige test av fargesyn? / Date of fost colour vision test AdOO [8 Sik for 7 Fi for ookout des? a7 Ves Nei NOL] |S Se siteresnkajond 7 oral fntons? Taos TE WaT WOLT [Slider t-annet arbeid om bord? /Fitfor other work on board? Ta es Wei MoT |"27-Shikket tl tjeneste uten begrensing? / Fit for service without limitations or restrictions? Ta/ ves 14 Nei NOL] 7 aT a a? RTT TETRA) Lege /Doctor[] _Fagnemnda / Appell | 7d00 AdOH = AdOO Tieneste om bord / Service Fartsomrade / Trade area Tr gn 6s a sp oo poe Wa a one ss era as ‘eakonnetie vegeta Janse oer aa floe ae pener om href? 1the sofort a oy med codon lt be egrovted by src te oro render he sefore nf fot suchsenice oro endanger the health of other persons onsard? sa/Yes(] _Nei/ no] 19. Legens navn / Name of docto 3 Lagens teonsumpe / Doctor phone pier Hi Lagens Kontoradresse/ Doctors office adil 2 Bi 22. Sjomannens signatur / Signature of seaforer 35. Uilgpadat for balaseriiringen Fewbiy date yz i¢ebrane 2001 hoof Sipeterhet,§17 lar re ew een. pe issued under the provisions of the Act of 16 February 2007 No.9 relating to ship Safetyand Security, ote meets the requirements set out inthe Maritime Labour Convention and the ICW Convention. Rater © cee ret wie suas © copy cory copy