Mariners Sight and Audition Test

MARINERS’ SIGHT AND AUDITION TEST

(In pursuance of section 8 of the Danish Maritime Authority’s Order No. 401 of 8 June 1989)

I the undersigned, who in compliance with section 8 in the Danish Maritime Authority’s Order No. 401 of 8 June 1989 on Manners’ Sight and Audition Test is authorized to carry out the sight test described in the Order, has examined

Date / Name
IO No. / Homeaddress
The examined has proved his identity to me by producing his / Discharge Book Passport Driving license

Having been informed about the meaning of night-blindness, the person examined certifies by his signature that he has not noted any difficulties in his sence of locality under low illumination, st. section 4.

______

(Signature of person examined)

Distance at the visual power test
I.
Examination in pursuance of section 3
II. / Visual power
without corr. / Right eye Left eye
Both eyes simultaneously
Visual power
with corr. / Righteye Lefteye
Both eyes simultaneously

If the person examined during the test uses contact lenses he shall by his signature certify that he has been informed of the provision of section 8 sub section 3, of the Order saying that a person using contact lenses shall always have available a pair of glasses of the same corrective effect as the contact lenses.

______

(Signature of person examined)

Is the visual field for finger movements normal, ct. section 4 / Right eye Yes No
Left eye Yes No
Is the colour vision normal, st. section 4
The test is undertaken by means of Ishihara’s “Test for Colourblindness Complete Edition” / Yes No
Number of misreadings
Is the audition normal, st. section 6 Yes No

According to me examination I can certify that

a. The person examined has passed the Mariner’s Sight and Audition Test according to section 3, st. sections 4 and 6
b. The person examined has not passed the Mariner’s Sight and Audition Test
c. It is doubtful whether the person examined has passed the Mariner’s Sight and Audition Test
Weak visual power Reduced visual field Uncertain colour vision Weak visual power in darkness Reduced audition
Doctor’s name / Date
Doctor’s signature

In foreign countries sight and sudation tests shall be conducted by on oplitainic surgeons only. The local Danish foreign representative on the certificate that the doctor who has losued the certificate is a locally authorized optitanic surgeon.

Date
Signature of local Danish foreign representative

DANISH MARITIME AUTHORITY Medical certificate for examination of seafarers

Parts A and B to be completed by the seafarer To be used only for persons of 16 years of age or older

A. / Surname / First name (s) / Date of birth
day month year / Sex
Male female
Nationality RUSSIAN
Home address (street, house number) / Postal code and town/city / Country
RUSSIA
B. / OWN DECLARATION / No / Yes / When (year) / OWN DECLARATION / No / Yes / When (year)
Have you previously served in Danish ships / Eye diseases
Have you previously under gone a medical examination for seafarers / Pain in the back including lumbago and sciatica
Have you been declared unfit for sea service or fit subject to limitations at any previous medical examination / Epilepsy or other convulsive fits
Mental disorders for which you have received medical treatment
Have you been admitted to hospital / Alcohol and drug abuse for which you have been treated
Have you within the last two years had unbroken periods of sick leave of more than 30 days / Hypersensitive reactions, including asthma
Do you have difficulties in orientating yourself under reduced lighting / Eczema
Do you suffer or have you suffered from any of the following diseases / Serious accidents causing permanent disability
Lung diseases, including pulmonary tuberculosis (TB) / Do you use medicine regularly
Stomach and intestinal diseases including gastric ulcer / I hereby give my consent that information about any previous diseases may be obtained from doctors, hospital other treatment centers and public authorities
Heart and circulatory diseases
Kidney and bladder diseases / Date Seafarer’s signature
Diabetes
Ear diseases
Part C to be completed by the doctor
C. / Doctor’s examination (see list of diseases and conditions)
Is the person examined known to you and does he/she use you as a doctor? / No Yes
The person examined is unknown to me, but has satisfied me as to his identity by showing me / Danish discharge book Driving license Passport
Height (cm) / BMI
NORMAL / Examination of vision and hearing
Weigh (kg) / Colour vision (Ishihara) Colour blindness
Urine / Alb. / Heart / Field of vision Yes
Sugar / Lungs / Vision acuity (See list par. V4) / without correction / with correction normally used
Blood pressure / Abdomen / Right eye
Teeth / Skin / Left eye
Eyes / Extremities / Both eyes simultaneously
Oral cavity / Hernia / Hearing (see VI) / Normal speech / Normal speech at a distance of 4 m / Otoscopy
Reflexes / Spinal column / Without hearing aid / Right ear
Special remarks (if any) / With hearing aid / Left ear
Result: Fit for look-out duty
Is the examined in your opinion fit for duty?
If “no” please state the reason
If fitness is conditional, state limitation in regard to
a) Time12 month / b) Field of work / c) Trading area
Place and date doctor’s stamp and signature
The certificate should be forwarded to the Danish Maritime Authority by the master or the shipping company. The doctor’s bill should be enclosed.

S-803E-2000