Bermud

GOVERNMENT OF BERMUDA
DEPARTMENT OF MARITIME ADMINISTRATION

SEAFARER MEDICAL FITNESS CERTIFICATE
Authorized by the Department of Maritime Administration, Government of Bermuda,
Issued under the Provisions of the International Convention on Standards of Training, Certification and Watchkeeping for
seafarers, 1978 as amended, The Maritime Labor Convention 2006, and Bermuda
Merchant Shipping (Medical Certification of Seafarers) Regulations 2013.
2.0 Seafarer Information
2.1 Family Name 2.1.1 First / Middle Name
Enter Family Name Enter First/Middle Name
2.2 Date of Birth: Enter Date 2.3 Gender: Male: ☐ Female: ☐
Seafarer’s
2.4 Nationality: Enter Nationality Photograph
2.4.1 Passport or Seaman’s Book Number: Enter Passport or SDB Name
Department: Rank/
(e.g. Deck/Engine/Catering/Other)
Enter Department Job:
Enter Rank/Job
3.0 Declaration of the Recognized Medical Practitioner (Standard to be met s per STCW C de Section A-I/9)
3.1 Seafarers Documentation checked at point of examination s ☐ No ☐
3.2 Hearing satisfactory Yes ☐ No
3.3 Unaided Hearing satisfactory Yes No ☐
3.4 Visual Acuity satisfactory s ☐ No ☐
3.5 Satisfactory Color Vision (Deck & Engine Only) Ye ☐ No ☐
3.6 Fit for Look-out Duties (Deck & Engine Only) Yes ☐ No ☐
**Visual Aids: (if worn specify which type Spectacles ☐ require carrying an additional pair
and for what purpose) Contact Lenses ☐ of spectacles
3.7 Medical Fitness Category
1. FIT ☐ No Restrictions or Limitations, Full Duration Yes ☐ o ☐
2. FIT ☐ Subject to Restrictions d/or Limited ration, See Below
++Restricted Duties: Enter Response
++Restricted to Ship Type/Geographical area/Other:
Enter Response
The above MUST NOT contain any clinical information
The Seafarer is free from any Medical condition likely to be aggravated by sea service or to
3.8
endanger thehealth of other persons on board. Yes ☐ No ☐
3.9 Examination Date: Enter Date. 3.10 Certificate Expiry Date: Enter expiry date
I confirm he above named seafarer was examined by me and found to be fit for sea service as stated in
Sections 3.7 and 3.8 abo e.
Enter Response
Please keep Signature within this box
4.0 Signature of dollarized Medical Practitioner Full Name (Print) of duly authorized Medical Practitioner
4.1 Medical Practitioner’s Official Stamp Medical Practitioner’s Contact Information:
Address: Enter Address
Phone: Enter Phone Number
E-mail: Enter E-Mail
5.0 Seafarer Declaration – I have been informed by the medical practitioner of the content of the medical certificate and of he
right to a review in accordance with paragraph 6 of section A-1/9 of the STCW Code in relation to medical fitness standards or
any limitations or restrictions imposed on ability to work. (see overleaf for review procedure)
Seafarer Signature: Please Keep Signature within this box Serial Number: Enter Serial Number
*All Certificates are valid for a Maximum of Two (2) Years from the Examination Date or One (1) Year if the seafarer Is under 18 years of age
Color vision tests are valid for Six (6) years.
THE ORIGINAL CERTIFICATE SHOULD BE ISSUED TO THE SEAFARER
BSME CERT FORM-5a

Bermuda Seafarer Medical Fitness Certificate_2014-01
6.0 Review Procedure
Medical Certificate Review Process

All seafarers that have been refused a medical certificate or have had a limitation imposed on their ability to work
must be given the opportunity to have a further examination by another independent medical practitioner or by
an independent medical referee.
A seafarer whose medical fitness certificate is suspended for more than three months or cancelled has the right of
review of that suspension or cancellation. All such seafarers will have been given m 6 or 7 with the details of
the process and the application form.
The examining medical practitioner should advise the seafarer in regards to procedure for medical review, in
accordance with paragraph 6 of section A-1/9 of the STCW Code in relatio n to medical fitness standards or
anylimitations or restrictions imposed on ability to work.
BSME CERT FORM-5a

Bermuda Seafarer Medical Fitness Certificate_2014-01

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GOVERNMENT OF BERMUDA

DEPARTMENT OF MARITIME ADMINISTRATION

BSME CERT FORM-5a

Medical Certificate Review Process

BSME CERT FORM-5a

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