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EXAMINATION AND CERTIFICATION OF SEAFARERS: COMPENDIUM

ANNEX 2

The Republic of lIberia ministry of finance bureau of maritime affairs

PHYSICAL EXAMINATION REPORT/CERTIFICATE

LAST NAME OF APPLICANT

FIRST NAME

MIDDLE INITIAL

DATE OF BIRTH   MONTH DAY YEAR

PLACE OF BIRTH   CITY COUNTRY

EXAMINATION FOR DUTY AS: MASTER * MATE * ENGINEER * RADIO OFF * SEAMAN *

MAILING ADDRESS OF APPLICANT

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:     RT EAR_______________________LEFT EAR___________________________

WITHOUT GLASSES

WITH GLASSES

COLOR TEST TYPE: BOOK * LANTERN *

Check if color test is normal

" YELLOW________RED_____GREEN________BLUE______

HEAD AND NECK ______________________________________________

HEART (CARDIOVASCULAR) ___________________________________________________________

LUNGS _______________________________________ ______________________________________________

SPEECH (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 onboard?

_________________________________________________ ________________________________ SIGNATURE OF APPLICANT DATE This signature be attired 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 SEAMAN)     NAME AND DEGREE OF PHYSICIAN__________________________________________________________________________________________________________ (PLEASE PRINT)     ADDRESS _______________________________________________________________________________________________________________________________   NAME OF PHYSICIAN’S LICENSING AUTHORITY_______________________________________________________________________________________________     DATE OF ISSUE OF PHYSICIAN’S LICENSE____________________________________________________________________________________________________   SIGNATURE OF PHYSICIAN_________________________________________________________________________________________________________________

This certificate is issued by authority of Liberian Maritime Regulation 10.325(2) and in compliance with the requirements

of the Medical Examination (Seafarers) Convention 1946 (ILO No/ 73)

ANNEX 2