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. In view of this, the Directorate in consultation with the

stakeholders has revised the existing M.S. Medical Examination Rules,

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. 1

Applicability:

5. This notice is applicable to the; 5.1 new entrant(s) seeking marine profession;

5.2 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 shall-

6.1. 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. be experienced in conducting medical fitness examination of

seafarer.

6.4. 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 1.2-

Medical Certificate, Regulation 3.1- Accommodation 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

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A-I/9-Medical standards, section B-I/9-Medical examination and

Certification and Resolution 8- Development of guidelines to

implement international standards of medical fitness for

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 may be gained either through special

instructions

suo-motu or courses relating to 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 /

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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 administrative procedures and clear

recommendations to approve, the Directorate General of

Shipping shall approve the Medical practitioner. The Medical

Practitioner thereafter shall be issued with letter of approval in

the prescribed format as specified in Schedule-II . This

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.  No further extension shall be

considered for medical examiners above 75 years of age.

6.17. 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

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examiner to the Directorate General of Shipping within 30 days

of such schedule through normal postal service.

Types of Medical Examination-

7. 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

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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 with any additional employer or insurer

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 seafarers-

ILO/IMO/JMS/2011/12. The medical examiner shall pay special attention to

the following as far as the examination and issuance certification of

seafarers;

12.1. Appendix A- Vision standards - STCW Code table A-I/9: Minimum in-

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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.

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13.4.2. vital signs - blood pressure, pulse rate and body

temperature etc;

13.4.3. vital Systems- respiratory, cardiovascular, nervous,

gastrointestinal and genitourinary etc;

13.4.4. 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

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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

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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 -cum-

Sr. 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 (Examinee’s 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

_________________

11

Jahaz Bhavan, Place

________________

Walchand Hirachand Marg,

Ballard Estate,

Mumbai-400 001.

[Kind Attn: Approving Authority (Nautical Adviser to the Government of

India) ].

[Subject:- Approval / Extension of approval to Medical examiner -regarding.]

Sir,

I, Dr. __________________________________ wish to apply for the

approval of Medical examiner / extension of approval to conduct medical

examination. 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.

2. Copy of bio-data with supporting documents including an affidavit

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3. Copy of check list duly filled in with relevant information.

4. Copy of proof of age.

5. Copy of previous letter of approval, if applicable. [Note:- A copy of

above mentioned documents shall be duly notarized or certified by

Gazette officer or self attested]

6. A proof for medical fitness by Government department in case of

extension.

7. A proof for filing periodical returns in case of extension.

8. A proof stating no pending complaints or legal proceedings for new

applicant and existing cases.

9. 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.

(ii) Medical publication “The International Medical guide for ships or an equivalent national medical guide for use on ships.

(iii) Standard of Training, Certification and Watchkeeping 1995 as amended REG I/9-Medical Examination.

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(iv) Maritime Labour Convention 2006- Medical Examination of Seafarers.

(v) International Labour Organization/World Health Organization/D.2/1997, as amended-Guidelines for conducting pre-sea and periodic medical fitness examination of seafarers.

(vi) Relevant provisions of Merchant Shipping Act, 1958, section 98 etc.

(vii) 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.

(viii) 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 meAttested

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,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

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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. This

approval shall remain valid for --- years till ----------- subject to the compliance

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 applicant-

Date of birth-

Name & address of clinic at which medical examination to be conducted –

PART B

Educational qualification with certified copies as attachment-

Professional qualification with certified copies as attachment (at least

M.B.B.S.)-

IMC registration number-

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Details 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 seafarers-

Details of other doctors, managerial, Para-medical and clerical staff including

consultants-

Details 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 Team-

Recommendations 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 :-

BI CBC

BI ESR

RBS / FBS

SGOT17

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 Tests-

Psychometric evaluation on case to case basis

Stress test

2D echo Doppler study (for heart patient)

Glycosylated (Hb1Ac)

Spirometry

3. Mandatory Examination and Tests (Certification of Competency and other

endorsements) subject to the candidate not having medical certificate.

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(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

Physical Examination: Weight, Height, Temperatures, pulse rate, Blood Pressure,

Sight ,Hearing , Oral Health , general appearance & systemic examination of the whole

body .

Blood Tests :-

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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 Tests-

Glycosylated (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 country’s regulations as applicable-

(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.

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(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.

(ii) Vaccination at the time of Periodic Medical Examination:

Note :-

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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.

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.

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1. Name (last, first, middle): _____________________________________________2. Date of birth (day/month/year): .. /.. /….

3. Sex: __ Male __ Female

4. Home address: _______________________________________________________

5. Method of confirmation of identity, e.g. Passport No./Seafarer’s book

No. or other relevant identity document No.: _____

6. Department (deck/engine/radio/food handling/other): _____

7. Routine and emergency duties (if known): _____

8. Type of ship (e.g. container, tanker, passenger): _____

9. Trade area (e.g. coastal, tropical, worldwide): _____

10. Examinee’s personal declaration

(Assistance should be offered by medical staff)

11. Have you ever had any of the following conditions?

Condition Yes No

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

Allergies

Infectious/contagious diseases

Hernia

Genital disorder

Pregnancy

Sleep problem

Do you smoke, use alcohol or drugs?

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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 Yes No 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?

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 Yes No

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Are you taking any non-prescription or prescription

medications?

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):

_________

------------------------------------------------------------------------------------------------------------

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14. MEDICAL EXAMINATION

Sight

Use of glasses or contact lenses: Yes/No (if yes, specify which type and for

what purpose)

___________________________________________________________________________

Visual acuity

___________________________________________________________________________

Unaided Aided

Right eye Left eye Binocular Right eye Left eye Binocular

___________________________________________________________________________

Distant

Near

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___________________________________________________________________________ Visual fields

__________________________________________________________________________Normal Defective

________________________________________________________________________Right eyeLeft eye

___________________________________________________________________________ Colour vision

Not tested Normal Doubtful Defective

Hearing

___________________________________________________________________________

Pure tone and audiometry (threshold values in dB) ___________________________________________________________________________ 500 HZ 1 000 HZ 2 000 HZ 3 000 HZ______________________________________________________________________________

Right earLeft ear

______________________________________________________________________________ Speech and whisper test (metres)

______________________________________________________________________________Normal Whisper

______________________________________________________________________________Right ear

Left ear

______________________________________________________________________________

15. Clinical findings

Height: _____ (cm) Weight: _____ (kg)

Pulse rate: _____/(minute) Rhythm: _____

Blood pressure: Systolic: _____ (mm Hg) Diastolic: _____ (mm Hg)

Urinalysis: Glucose: _____ Protein: _____ Blood: _____

______________________________________________________________________________

Normal Abnormal

______________________________________________________________________________

Head

Sinuses, nose, throat

Mouth/teeth

Ears (general)

Tympanic membrane

Eyes

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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): ../../….

Results:

17. Other diagnostic test(s) and result(s):

Test: Result:

Medical practitioner’s comments and assessment of fitness, with

reasons for any limitations:

18. Assessment of fitness for service at sea

On the basis of the examinee’s 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)

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Deck service Engine service Catering service Other

services

Fit

Unfit

Without restrictions with restrictions Visual aid required Yes No

Describe restrictions (e.g., specific position, type of ship, trade area & others

as applicable):

Medical certificate’s date of expiration (day/month/year): ______/______/______

Date medical certificate issued (day/month/year): ______/______/______

Number of medical certificate:

________________________________________________

Signature of approved medical examiner:

_____________________________________

Approved Medical examiner information (name, license number, approval

number, address):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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

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APPROVED MEDICAL EXAMINER NAME AND ADDRESS

Last/Family Name First Name

Position applied for ID (Passport/Discharge book) No:

Date of Birth Sex Nationality

Company Name 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 seafarer’s/ 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) that the hearing meets the required STCW standards section A-I/9:- Yes / No

(b) Unaided hearing is satisfactory Yes / No

(c) Visual acuity meets the required STCW Code standards section A-I/9Yes / No

(d) Color Vision meets the required STCW Code standards section A-I/9Yes / No

(testing only required every 6 years unless considered necessary )

(e) Date of last color vision test ( Day/Month/Year) ……………………..

(a) Fit for look out duty Yes / No

(b) No. limitation or restrictions on fitness Yes / No

(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) ………………………

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Photo

(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:

Approving Authority of Medical Examiner: Directorate General of

Shipping, Govt. of India.

Schedule VIII

Half Yearly Returns FormatSUMMARY OF MEDICAL EXAMINATION CONDUCTED FOR THE PERIOD

FROM ------------ TO ----------

Sr. No.

Name of the seafarer

Date of Birth/Rank

Male / Female

CDC No.

Pre sea / Periodic or additional examination

Name of shipping Company /training

Unfit / Temporary Permanent

If unfit reason(s) for unfitness

If referred to Authority

30

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:

institute

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

******

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