Maritime Medical Certificate Format
Maritime Medical Certificate Format
Form-INEA-21-000-5
PERSONAL INFORMATION
| Medical History No: | Certificate No: | ||
| Surname: | |||
| Name: | |||
| ID Card No.: | Sex: | |
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| Height (Mts): | Weight (Kgs): | ||
| BMI: | Nationality: | ||
| Examination for duty as: |
OTHERS:
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| Place and date of birth: | |||
| Address:
Phone: E-mail: |
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SECCION B. FILLED BY THE DOCTOR
| Audiometry in accordance of standards of section AI/9 | |||
| Right Ear | Left Ear | ||
| No hearing aids: Hearing meets the standards of section AI/9? |
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| Visiometry in accordance of standards of Section AI/9 | |||
| Eye | UNCORRECTED | CORRECTED | TEST ISHIHARA |
| Right | Color Vision meets the standards? Date of last color vision test: |
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| Left | |||
| Both eyes | |||
| Visual acuity meets the standards? |
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SECCION C. APTITUDE
| The examinee is suitable for tasks watch? (Specify): |
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| The examined presents any restrictions or limitations regarding physical fitness? (Specify): |
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| Cardiac Evaluation (Over 40 years of age) | Complementary Exams | ||
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| The person is free from any condition likely to be aggravated by service at sea or incapacitate as result of work or represent danger to the health of other persons on board? (Specify): |
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SECCION D. CERTIFICATE VALIDITY
| Date of issued: | Expiration Date: | ||
| Confirm that I have been informed about the content of this certificate | Physician Name: | ||
| Seafarer Signature: | Physician’s Stamp: |
Stamp
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| Address: | Physician Signature: | ||
DESCRIBE THE OBSERVATION ACCORDING TO THE CORRESPONDING SECTION
| Medical History No: | Certificate No: |
| SECCION | OBSERVATIONS |
|---|---|
| SECCIÓN B) AUDIOMETRY | |
| SECCIÓN C) CARDIOLOGICAL EVALUATION AND CHEST X-RAY | |
| Mental Health | |
| Laboratory Tests | |
| Others | |
| Limitation or restriction | |
| Aptitude |
Physician Signature and Stamp
Seafarer Signature
Decree with Rank, Value, and Force of Law on Marinas and Connected Activities, article 283. Holders and possessors of Licenses and Permits referred to in this Decree with Rank, Value, and Force of Law must submit a maritime medical certificate to the National Institute of Aquatic Spaces (INEA), demonstrating their physical and mental fitness to perform the duties inherent to their respective functions on board vessels. The applicable regulations shall govern all matters regarding this certificate.
