Norwegian Maritime Directorate

Sjøfartsdirektoratet
Norwegian Maritime Directorate / Form for medical examination
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CONFIDENTIAL
Form to be used in medical examination of employees on ships (For doctor’s use only, to be kept by the doctor in accordance with the rules on storage of medical information in force at any time in the country concerned.)
A) PERSONAL INFORMATION
Passport number, sea service book or other proof of identity indicate type of document and ID number:
Date of birth: (day/month/year): / / / Sex: / Male / Female
Full name in block letters:
Family name:
First name: / Middle name:
Place of residence (home address)
Nationality
Marital status: / married/cohabitant: / unmarried: / widow/widower:
Service on board: / Position on board:
Navigational watch function: / Yes / No
If Yes, master, navigator, other function
Safety function: / Yes / No
If Yes, which function(s)?
Type of ship: / dry cargo ship (bulk, container etc.) / passenger ship (ferry, cruise etc.)
tanker (oil, gas, chemical) / high-speed craft
fishing vessel / supply vessel
other types of ship / which?
Trade area: / which area(s)?
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B) SELF-DECLARATION
Do you have a limited health certificate today? / Yes / No
If Yes, indicate the limitation(s)
Have you ever applied for exemption from health, sight or hearing requirements? / Yes / No
If Yes, what was the decision?
Have you ever been granted sick leave from ship? / Yes / No
If Yes, why?
Have you ever been declared medically unfit for service on board ship? / Yes / No
If Yes, why?
Do you have any illness or other medical condition which is known to you? / Yes / No
If Yes, indicate any such illness or condition?
Do you use medical drugs or other medicines regularly? / Yes / No
If Yes, what kind(s)?
Have you been hospitalized? / Yes / No
If Yes, why?
Have you had trouble with sleep? / Yes / No
If Yes, describe such trouble
Have you ever had any nervous or mental condition? / Yes / No
If Yes, describe such condition
Have you har trouble with drug or alcohol abuse? / Yes / No
If Yes, describe such trouble
Have you had any serious allergic reaction/eczema/skin disease? / Yes / No
If Yes, what caused the reaction?
Have you ever been unconscious or dizzy? / Yes / No
If Yes, describe
Do you have any injury or injuries causing persistent incapacity, pain or trouble? / Yes / No
If Yes, describe
Have you experienced diarrhoea over the last three months? / Yes / No
If Yes, describe
Have you been abroad recently? / Yes / No
If Yes, where?
Are you using or do you need contact lenses or glasses to see normally? / Yes / No
Are there any other aspects of your health which may affect your capacity for work? / Yes / No
If Yes, describe
Do you feel that your health is such to make you fit for your intended service? / Yes / No
If No, why?
I agree to the collection of information, where necessary, about any previous, illness or medical condition from social security offices, doctors, hospitals, other medical institutions or any public authority, as appropriate.
I am aware that pursuant to the provisions of the Seamen’s Act I am not entitled to some of the shipping company benefits referred to therein if I have acted fraudulently in not providing information about any illness, medical condition or injury known to me prior the commencement of service (ref. Seamen’s Act of 30 May 1975 No. 18).
I am aware that “anyone who serves on a ship without possessing the qualifications for the position (…), shall be punished by fines or by imprisonment of up to 3 months” (§424 of the General Civil Penal Code of 22 May 1902 No. 10).
Place: / Date (day/month/year): / /
Signature of employee
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C) MANDATORY EXAMINATION
Height: / cm
Weight: / kg
Laboratory testing:
Urine-stix (+ or -): / protein / glucose / RBC / WBC
Hb / / / g/dl / SR / mm/hr
Blood pressure / /
Tuberculosis checks:
Employees have to undergo tuberculosis checks in accordance with the rules in force at any time pursuant to the Communical Diseases Control Act of 5 August 1994.
X-ray, lungs (date and result)
(x-ray must at least measure 100 by 100 millimetres)
Pirquets test or Mantoux test (date and result)
Other
Examination of hearing:
Audiometry using pure tone audiometer:
Hz / 250 / 500 / 1000 / 2000 / 3000 / 4000 / 6000
Right ear
Left ear
Without audiometer:
The result is satisfactory considering the applicable provisions in force / Yes / No
If the result is not satisfactory may the employee, considering the applicable provisions in force, be permitted to use a hearing aid to achieve acceptable hearing? / Yes / No
In cases of doubt, guidance should be provided on the possibility of being examined by a specialist using speech audiometry and of subsequently applying for exemption from the requirements in force.
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Examination of sight:
Sight (distance – 5m):
Right eye / Left eye / Both eyes / Confirming to requriements
Yes / No
uncorrected
corrected
contact lenses
glasses
Field of vision:
Right / Left / Remarks if not normal:
Normal
Not normal
Colour vision: / Test(s) used:
normal / Ishihara
not normal / Lantern test
not examined
The use of contact lenses or glasses to improve colour vision is not permitted.
For employees who do not pass an Ishihara colour test conducted by a seamen’s doctor, guidance should be provided on the possibility of being examined by a specialist using the lantern test and of subsequently applying for exemption from the requirements in force.
Eye conditions
Eye diseases or disorders/defects for which the employee has no possibility to receive necessary treatment on board.
Type(s) of condition?
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Clinical examination:
Are there any symptoms or signs of the following: / Yes / No
1. / communication problems?
2. / physical late effects of injury/illness or congenital deformations?
3. / nervous conditions, emotionally unstable?
4. / skin diseases?
5. / abnormal findings in lymph gland, thyreoidea pulse by palpation?
6. / infectious disease or inflammatory condition?
7. / cardiovascular disease?
8. / abnormal findings by ausculatation of heart, lungs or carotid artery?
9. / disease or condition of the muscular or skeletal system?
10. / neurological disease/conditions?
11. / endocrine diseases?
12. / pathological enlargement of lymph glands?
13. / diseases of the teeth and/or gums?
14. / gastro-intestinal diseases/conditions?
15. / disease/condition in urogenital tract?
16. / disease/condition in mammary glands?
17. / lung or lung-related disease?
18. / short of breath, chronic pain?
19. / sleeplessness?
20. / chronic or acute physical disorders/conditions?
21. / chronic or acute mental condition or mental illness?
22. / drug and/or alcohol abuse?
If you in your capacity as seamen’s doctor answer Yes to any of those above questions, additional information should be
given below:
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VACCINATION (A review of the vaccination status is recommended. In some countries, vaccination is a precondition for any permission to stay within their territory.):
Vaccines / Date / Date / Date / Date / Valid until
BCG
YELLOW FEVER
CHOLERA
DIPHTERIA/TETANUS
POLIO
HEPATITIS A
HEPATITIS B
JAPANESE ENCHEPHALITIS
Decision:
The employee is medical fit for the intended service / Yes / No
If Yes:
On the basis of the employee’s self-declaration, the results of the above examination of sight and hearing, the clinical examination and the laboratory testing, a health certificate is issued to:
family name / middle name / first name
who is found to be medicallly fit for service in the intended position and the functions identified by the employee, ref. Regulation of 19 October 2001 concerning the medical examination of employees on ship the appurtenant appendix.
There are no limitations
The following limitations are decided by the seamen’s doctor concerning the validity of the health certificate:
position:
function:
trade area:
ENTER THE SERIALNUMBER FROM THE FORM HEALTH CERTIFICATE ON THIS FORM.
If NO:
The form Declaration of unfitness must be completed in accordance with the guidelines for that form. REMEMBER TO ENTER THE SERIAL NUMBER from the form Declaration of unfitness on this form.
Reasons for decision on unfitness on medical grounds or limited health certificate:
(The employee must be informed about the right to appeal and to apply for exemption.)
Date (day/month/year) / Signature of approved seamen’s doctor
KS-0497 E (12.2001 Sdir) / 2