MEDICAL CERTIFICATE

FOR PERSONNEL ON SERVICE ABOARD

NAME: ____________________________________________________________________________________________________
SURNAME
FIRST NAME
MIDDLE NAME
BIRTH DATE: ___________/_________________________/__________
DAY
MONTH
YEAR

GENDER

Male

Female

POSITION ABOARD: ____________________________________________NATIONALITY:____________________________

ADDRESS:_________________________________________________________________________________________________
I.D. CARD OR PASSPORT N: ________________________________________________________________________________

VISION

COLOR PERCEPTION

AUDITION

NOT CORRECTED

CORRECTED

________BOOK

RIGHT EAR ______________

RIGHT EYE

20/

20/

________LANTER

LEFT EAR _______________

LEFT EYE

20/

20/

YELLOW__________ RED __________

BOTH EYES

20/

20/

GREEN ___________ BLUE __________

DECK SERVICE

ENGINE SERVICE

SERVICE OF
CAMERA

OTHERS SERVICES

APT
NOT APT

W ithout restrictions

With restriction

Need visual correction:

Yes:

Not:

Comments of the Medical Record and Physical Exploration

As a doctor duly authorizes by the Panama Maritime Authority, I have examined the above person, in accordance with the nacional
and international standard. Taking in consideration, the physical examination, personal statements of the examined person and the
results of the laboratory tess carried out, I DECLARE that he/she is:
Apt/ match stand ng

Not apt/ match standing

Place of physical examination: _______________________________________________________

Name of Clinic
_______________________________________________________
City / Country
Physical Examination Date: _____________/_____________/________________
Expiration Date of this Medical Certificate: _____________/_____________/_______________
Not of the Authorized Examining Doctor: _____________________________________________________
Print

_____________________________________________
Signature of Examining Doctor
Seal of Examining Doctor

Hereby I declare that I am in knowledge of the contents of the Physical Examination carried out: (signature of
the examined person):__________________________________________

This Certificate, will have a validity of two (2) years from the date of its issue.
" STCW 95, rule I/9. Medical standards issue and Registration of Certificates
" Resolution JA N 009-2001. Chapter XIII Medical standards, Articles 54
Medical fitness for seafarers.
" ILO / WHO/A.2/1997 Policies to establish standards of medical fitness for
seafarers previous and within the seagoing service according with the he
International Labour Organization (ILO) and the Health World Organization
(OMS).
Resolution ADM -082 -2001, whereby is approved and it published the list of
authorized doctors to carry out medical examinations for seafarers and recognized
by the Panama Maritime Authority.

Seal
Panama Maritime Authority
TIT-F-009 REV 02