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    Liberian Medical Form PDF

    Uploaded by

    Arpit Roy
    This physical examination report form is used to document the medical examination of an applicant for a maritime position. It collects information such as name, date of birth, physical measurements, vision and hearing tests, and an evaluation of general health and physical ability to perform duties at sea. The physician must certify whether the applicant is fit for the intended duty, such as master, engineer or radio officer. The form is issued in accordance with international maritime conventions on seafarers' medical examinations.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Liberian Medical Form PDF

    Uploaded by

    Arpit Roy
    2K views2 pages
    This physical examination report form is used to document the medical examination of an applicant for a maritime position. It collects information such as name, date of birth, physical measurements, vision and hearing tests, and an evaluation of general health and physical ability to perform duties at sea. The physician must certify whether the applicant is fit for the intended duty, such as master, engineer or radio officer. The form is issued in accordance with international maritime conventions on seafarers' medical examinations.

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    This physical examination report form is used to document the medical examination of an applicant for a maritime position. It collects information such as name, date of birth, physical measurements, vision and hearing tests, and an evaluation of general health and physical ability to perform duties at sea. The physician must certify whether the applicant is fit for the intended duty, such as master, engineer or radio officer. The form is issued in accordance with international maritime conventions on seafarers' medical examinations.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2K views2 pages

    Liberian Medical Form PDF

    Uploaded by

    Arpit Roy
    This physical examination report form is used to document the medical examination of an applicant for a maritime position. It collects information such as name, date of birth, physical measurements, vision and hearing tests, and an evaluation of general health and physical ability to perform duties at sea. The physician must certify whether the applicant is fit for the intended duty, such as master, engineer or radio officer. The form is issued in accordance with international maritime conventions on seafarers' medical examinations.

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    © All Rights Reserved
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    of 2

    PHYSICAL EXAMINATION REPORT/CERTIFICATE

    DEPUTY COMMISSIONER OF MARITIME AFFAIRS


    ANNEX 2
    THE REPUBLIC OF LIBERIA
    LAST NAME OF APPLICANT FIRST NAME MIDDLE
    INITIAL
    DATE OF BIRTH PLACE OF BIRTH SEX

    MONTH DAY YEAR CITY COUNTRY MALE¨ FEMALE


    EXAMINATION FOR DUTY AS: MAILING ADDRESS OF APPLICANT:
    MASTER
    MATE
    ENGINEER
    RADIO OFF
    RATING
    MEDICAL EXAMINATION (SEE REVERSE SIDE FOR MEDICAL REQUIREMENTS) STATE DETAILS ON REVERSE SIDE
    HEIGHT WEIGHT BLOOD PRESSURE PULSE RESPIRATION GENERAL APPEARANCE

    VISION: RIGHT EYE LEFT EYE HEARING:


    WITHOUT GLASSES __________ / _________
    WITH GLASSES __________ / _________ RT. EAR _______________ LEFT EAR _______________

    COLOR TEST TYPE: BOOK ¨ LANTERN ¨ CHECK IF COLOR TEST IS NORMAL YELLOW ___ RED ___ GREEN ___ BLUE ___

    HEAD AND NECK HEART (CARDIOVASCULAR)

    LUNGS SPEECH (DECK/NAVIGATIONAL OFFICER AND RADIO OFFICER)


    IS SPEECH UNIMPAIRED FOR NORMAL VOICE COMMUNICATION?

    EXTREMITIES:

    UPPER ______________________________________________ LOWER ___________________________________________


    IS APPLICANT SUFFERING FROM ANY DISEASE LIKELY TO BE AGGRAVATED BY, OR TO RENDER HIM UNFIT FOR SERVICE AT SEA OR LIKELY
    TO ENDANGER THE HEALTH OF OTHER PERSONS ON BOARD?

    _______________________________________________________ ______________________________________________
    SIGNATURE OF APPLICANT DATE

    THIS SIGNATURE SHOULD BE AFFIXED IN THE PRESENCE OF THE EXAMINING PHYSICIAN.

    THIS IS TO CERTIFY THAT A PHYSICAL EXAMINATION WAS GIVEN TO: ____________________________________________________________


    (NAME OF APPLICANT)

    (HE) (SHE) IS FOUND TO BE (FIT) (NOT FIT) FOR DUTY AS A: (MASTER, MATE, ENGINEER, RADIO OFFICER OR RATING)

    NAME AND DEGREE OF PHYSICIAN ______________________________________________________________________________________________

    ADDRESS ____________________________________________________________________________________________________________________________

    NAME OF PHYSICIAN'S CERTIFICATING AUTHORITY __________________________________________________________________________

    DATE OF ISSUE OF PHYSICIAN'S CERTIFICATE__________________________________________________________________________________

    SIGNATURE OF PHYSICIAN _______________________________________________ DATE:____________________________________

    This certificate is issued by authority of the Deputy Commissioner of Maritime Affairs, R.L. and in compliance with the
    requirements of the Medical Examination (Seafarers) Convention 1946 (ILO No. 73)

    RLM-l05M (REV. 12/96) 1


    MEDICAL REQUIREMENT

    All applicants for an officer certificate, Seafarer's Identification and Record Book or certification of special
    qualifications shall be required to have a physical examination reported on this Medical Form completed by a
    certificated physician. The completed medical form must accompany the application for officer certificate,
    application for seafarer's identity document, or application for certification of special qualifications. This physical
    exa mination must be carried out not more than 12 months prior to the date of making application for an officer
    certificate, certification of special qualifications or a seafarer's book. Such proof of examination must establish that
    the applicant is in satisfactory physical condition for the specific duty assignment undertaken and is generally in
    possession of all body faculties necessary in fulfilling the requirements of the seafaring profession. In addition, the
    following minimum requirements shall apply:

    (a) All applicants must have hearing unimpaired for normal sounds and be capable of hearing a whispered
    voice in the better ear at 15 feet and in the poorer ear at 5 feet.

    (b) Deck officer applicants must have (either with or without glasses) at least 20/20 vision in one eye and at
    least 20/40 in the other. If the applicant wears glasses, he must have vision without glasses of at least
    20/160 in both eyes. Deck officer applicants must also have normal color perception and be capable of
    distinguishing the colors red, green, blue and yellow.

    (c) Engineer and radio officer applicants must have (either with or without glasses) at least 20/30 vision in one
    eye and at least 20/50 in the other. If the applicant wears glasses, he must have vision without glasses of at
    least 20/200 in both eyes. Engineer and radio officer applicants must also be able to perceive the colors red,
    yellow and green.

    (d) An applicant's blood pressure must fall within an average range, taking age into consideration.

    (e) Applicants afflicted with any of the following diseases or conditions shall be disqualified: epilepsy,
    insanity, senility, alcoholism, tuberculosis, acute venereal disease or neurosyphilis, AIDS and/or the use of
    narcotics.

    (f) Deck/Navigational officer applicants and Radio officer applicants must have speech which is unimpaired
    for normal voice communication.

    (g) Applicants for able seaman, bosun, GP -1, ordinary seaman and junior ordinary seaman must meet the
    physical requirements for a deck/navigational officer's certificate.

    (h) Applicants for fireman/watertender, oiler/motorman, pumpman, electrician ,wiper, tankerman and survival
    craft/rescue boat crewman must meet the physical requirements for an engineer officer's certificate.

    IMPORTANT NOTE:
    The yellow copy of t he RLM-105M must accompany the application. The applicant must retain the original (white copy) of the RLM-105M as
    evidence of physical qualification while serving on board a vessel.

    DETAILS OF MEDICAL EXAMINATION


    (To be completed by examining physician)

    _____________________________________________________________________________________________________________________

    _____________________________________________________________________________________________________________________

    _____________________________________________________________________________________________________________________

    _____________________________________________________________________________________________________________________

    _____________________________________________________________________________________________________________________

    _____________________________________________________________________________________________________________________

    _____________________________________________________________________________________________________________________

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