PROCLAMATIONS, RULES AND REGULATIONS MARITIME AUTHORITY OF JAMAICA
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1 PROCLAMATIONS, RULES AND REGULATIONS MARITIME AUTHORITY OF JAMAICA MEDICAL FITNESS CERTIFICATE Issued under the Shipping (Medical Examination) Regulations, 1998 Seafarer s Name... Discharge Book No... Date of expiry of this Certificate... *Delete as appropriate I certify that I have examined the seafarer named above to the Medical and Visual Standards for Serving Seafarers as contained in the First Schedule of the above-named Regulations and have found *him/her fit for seafaring subject to the following restrictions: Official Stamp Signed... (A registered medical practitioner approved by the Authority) Date of Examination... Page 1 of 7
2 APPLICATION FOR REVIEW OF DECISION TO: *Refuse to issue a Medical Certificate *Impose Restriction on Medical Certificate *Suspend or Cancel Medical Certificate (Delete whichever is inapplicable) PROCLAMATIONS, RULES AND REGULATIONS I hereby apply for a review of the above decision and request that arrangements be made for me to be examined by an independent medical referee. I agree that a report of my case may be submitted to the medical referee by the medical practitioner concerned. I understand that I am entitled to present any medical evidence available to me in support of my case and agree to any medical report prepared by the above doctor being made available to the medical referee. This part to be completed by the person who is appealing Signed... Address... Name (in block letters... Telephone No. (if available)... Note: Before lodging an appeal, you are advised to consult your usual medical practitioner and, should you wish to submit medical evidence in support of the appeal, you should arrange for this to be sent to the medical referee before the appointment date. You will be advised of the name and address of the referee and the date for your appointment as soon as this has been arranged. Page 2 of 7
3 RECORD OF MEDICAL EXAMINATION OF SEAFARERS REPORT OF MEDICAL EXAMINATION BY AN APPROVED MEDICAL PRACTITIONER 1. Personal Details of Seafarer 4. Previous Medical History Surname... Does the seafarer have a medical history of one of the Following? If so (please tick the box) one of the following? Forenames... If so (please tick the box). Discharge Book No... Hypertension Title Mr Mrs Miss Ms Eye trouble/squint Stomach/bowel disorder Any other title held... E N T Date of Birth... Hearing impaired day month year Skin disease/allergies Rank/Rating/Occupation... Heart condition/rheumatic fever 2. Usual Medical Practitioner or Medical Advisor Asthma/bronchitis Name:. Hay fever/allergies Address.. Epilepsy/fits/fainting Nervous/mental illness Jaundice/liver disease/piles 3. Family Medical History Urinary disorders Has any member of the seafarer s family ever suffered Back injury/pain from: Hernia please tick correct box Diabetes Yes No Female disorders Pregnancy Hypertension Infectious/contagious/tropical diseases Malignant diseases Heart Conditions Migraine/severe headaches Head injury/concussion Asthma AIDS Hepatitis B Diabetes Tobacco intake (quantity) Alcohol intake (quantity. Mental Disorder Epilepsy Is the Seafarer now receiving any treatment?... Signature of Seaman... I certify that this is a true statement Page 3 of 7
4 5. Medical Examination Does the seafarer suffer from any of the following abnormalities? Please tick correct box and expand as necessary. Tooth HIV E N T Hepatitis B Skin CBC Heart VDRL Lungs Stool (Parasitology and Culture) Nervous system Blood Sugar (Random) Varicose veins Urinalysis Genito urinary system Chest X-Ray Hernia Any other defects Height (without shoes). m cm Weight (stripped to waist)...kilos Chest inspiration...cm Expiration...cm Pulse rate... Blood pressure systolic... 5 th Sound... Result of urine test: Albumin... Sugar... Audio (if equipment is available) Right Ear Khz db Left Ear Khz db 500 1,000 2,000 4,000 6,000 8,000 Distant Vision Unaided R6 L6 Both 6 aided Aided R6 L6 Both 6 Near vision Color vision Unaided N Aided N 500 1,000 2,000 4,000 6,000 8,000 Ishihare Engineers modified 7. Results Medical Examination The Standards of Medical Examination Regulations have been or have not been met. Tick correct box A. Unrestrictive sea service B. Permanently E. Restrictive Service only C. Indefinitely Restriction... (Review in.months) Period of restriction... D. Temporarily (Review in.. Weeks) Medical Practitioner s Official Stamp Signature... Name... (Block capitals) Date... Page 4 of 7
5 MEDICAL PRACTITIONERS ANNUAL RETURN OF MEDICAL EXAMINATIONS OF SEAFARERS Return for Period... Medical Practitioner s Name... Address of Surgery... (Details should only be entered in the columns below when a full certificate of fitness has not been granted. Appropriate boxes should be ticked to show reasons for failure. If you need more space continue on another form). BREAKDOWN OF REASONS FOR REFUSALS: (Use one column for each examination) Infectious/contagious diseases Malignant neoplasms Eyesight E N T Speech defects Respiratory system Cardiovascular system Disease of veins Gastro-intestinal system Page 5 of 7
6 Continued BREAKDOWN OF REASONS FOR REFUSALS: (Use one column for each examination) Skin Sexually transmissable diseases Genito-urinary system Gynaecological disorder Endocrine disease/metabolic disorder Central nervous system Alcohol abuse Musculo/skeletal system Psychiatric disorders BREAKDOWN OF REASONS FOR RESTRICTIONS: Infectious/contagious diseases Malignant neoplasms Eyesight E N T Speech defects Page 6 of 7
7 Continued BREAKDOWN OF REASONS FOR RESTRICTIONS: (Use one column for each examination) Respiratory system Cardiovascular system Disease of veins Gastro intestinal system Skin Sexually transmissable diseases Genito-urinary system Gynaecological disorder Central nervous system Alcohol abuse Musculo/skeletal system Psychiatric disorders S U M M A R Y TOTAL MO. OF APPLICATIONS DURING THIS PERIOD TOTAL ISSUED WITHOUT RESTRICTIONS THIS PERIOD TOTAL ISSUED WITH RESTRICTIONS THIS PERIOD TOTAL REFUSED THIS PERIOD Please return completed form to: The Director of the Maritime Authority of Jamaica. Page 7 of 7
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