NEW Medical certificate seafarers form 2016-1 PANAMA


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PLACE OF BIRTH
SEX
CITY COUNTRY
MALE
FEMALE
POSITION ON BOARD
MASTER
DECK OFFICER
ENGINEERING OFFICER
RADIO OFFICER
RATING
DECLARATION OF THE AUTHORIZED PHYSICIAN
COLOR TEST TYPE
GLASSES
WITH
GLASSES
BOOK
RIGHT EYE
LANTERN
YELLOW ______ RED ______
LEFT EAR __________
LEFT EYE
GREEN ______ BLUE ______
Hereby I declare that I am in knowledge of the contents of the physical examination
OFFICER/ RADIO OPERATOR/ RATING) (WITHOUT ANY / WITH THE FOLLOWING RESTRICTIONS :
Able for watchkeeping: YES NO
Is applicant taking any non-prescritption of prescription medications? YES NO
EXPIRY DAE OF CERTIFICATE :This certificate is valid upto one contract one year
Visual acuity meets standards in STCW code, Section A-1/9 YES NO
DATE OF BIRTH
GIVEN NAME:
MEDICAL CERTIFICATE SEAFARERS
with the requirement of the STCW Convention, 1978 as amended and Maritime Labour Convention 2006
SURNAME :
DAY MONTH YEAR
MAILING ADDRESS OF APPLICANT
NAME OF PHYSICIAN'S CERTIFICATING AUTHORITY
SIGNATURE OF PHYSICIAN ____________________ STAMP OF PHYSICIAN________________________DATE ________________
NAME AND DEGREE OF PHYSICIAN :
ADDRESS :
VISION
HEARING
RIGHT EAR __________
Hearing meets the standards in STCW code, Section A-1/9 YES NO NOT APPLICABLE
Confirmation that identification document were checkd at the point of examination : YES NO
Colour vision meets standards in STCW Coad
,
Section A
-
1
/
9
YES NO
(
THE VISUAL TEST IT IS REUIRED EVERY SIX YEARS
)
Date of the last colour vision test
:
(
Day
/
Month
/
Year
)

______
/
_______
/
Is the seafarers free from any medical condition likely to be aggravated by service at sea or render the seafarers unfit for such service or to endanger the
health of other persons on board? YES NO
Unaided hearing satisfactory? YES NO

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