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    Seafarers Medical Certificate

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    thebettfourfamily
    certificate

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    © All Rights Reserved
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    Seafarers Medical Certificate

    Uploaded by

    thebettfourfamily
    31 views1 page
    certificate

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    Seafarers medical certificate

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    certificate

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    31 views1 page

    Seafarers Medical Certificate

    Uploaded by

    thebettfourfamily
    certificate

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    FC05 Rev.

    01/23

    REPUBLIC OF KENYA

    KENYA MARITIME AUTHORITY

    SEAFARER MEDICAL CERTIFICATE


    Issued under Regulation 6 of the Merchant Shipping (Seafarer Medical Examination and Certification) Regulations, 2016
    Certificate No: M-
    SEAFARER INFORMATION
    Last name: First name: Middle name(s):

    Nationality: Passport No: Date of Birth: Discharge book No:

    Gender: ☐ Male ☐ Female Rank/Job: Department:


    This is to certify that above named seafarer has been examined in accordance with the Seafarers' medical fitness standards
    and certification requirements established in accordance with the provisions of regulation I/9 of the STCW Convention,1978
    as amended, and regulation1.2, Maritime Labour Convention, 2006 as amended and found to be fit for sea service, subject
    to any limitations indicated
    DECLARATION OF THE RECOGNIZED MEDICAL PRACTITIONER
    Yes No
    1.Confirmation that identification documents were checked at the point of examination ☐ ☐
    2. Hearing meets the standards in STCW Code Section A -I/9? Date of test (dd/mm/yyyy): ☐ ☐

    3. Unaided hearing satisfactory? ☐ ☐


    4. Visual acuity meets standards in section A-I/9? Visual aids (if worn): Spectacles: ☐ Contact lenses: ☐ None: ☐ ☐ ☐
    5. Colour vision meets standards in section A -I/9? Date of last color vision test: ☐ ☐

    6. Fit for look-out duties? (Deck and Engine Dept. only) ☐ ☐


    7. Limitations or restrictions on fitness? ☐ ☐
    If “Yes”, specify limitations or restrictions: Examination form No:

    8. 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?
    Date of Issue Date of Expiry*

    RECOGNIZED MEDICAL PRACTITIONER REGISTRAR OF KENYAN SEAFARERS


    Sign: _ _ _ _ _ _ _ _ _ _ _ _ _ _ Sign: _ _ _ _ _ _ _ _ _ _ _ _ _ _

    Name (print): _ Name (print): _

    Place of examination: _ Place of issue: _

    Seal/Stamp: _______________________________ Seal/Stamp: ________________________

    Seafarer’s declaration: I hereby confirm that I have been informed about the content of this certificate and my right to appeal in accordance
    with the Merchant Shipping (Seafarer Medical Examination and Certification) Regulations, 2016.

    Signature of the seafarer: ____________________________

    *Valid for a maximum period of two years unless the seafarer is under the age of 18, in which case the maximum period of valid ity shall be one year.

    For Safe and Efficient Water Transport


    ISO 9001:2015 Certified

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