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GUIDE

East Coast Medical Assessment For Fitness to Work Offshore


May 2001

2001-0005

Canadian Association of Petroleum Producers (CAPP) represents 150 companies whose activities focus on exploration, development and production of natural gas, natural gas liquids, crude oil, synthetic crude oil, bitumen and elemental sulphur throughout Canada. CAPP member companies produce approximately 95 per cent of Canadas natural gas and crude oil. CAPP has 120 associate members who provide the broad range of services that complete the infrastructure of this countrys upstream crude oil and natural gas industry.

Supersedes 1988-0001 Review by May 2004 DOCs #22677

Disclaimer
This report is a modification, completed by members of CAPPs East Coast Safety Committee and with the assistance of representatives from the CAPP Occupational Health Committee. The document was initially compiled by a non-CAPP committee named the East Coast Occupational Health Advisory Committee. While it is believed that the information contained herein is reliable under the conditions and subject to the limitations set out, neither CAPP nor its committees guarantees its accuracy. The use of this report or any information contained will be at the users sole risk, regardless of any fault or negligence of CAPP or its committees.

2100, 350 - 7 Avenue S.W., Calgary, Alberta T2P 3N9 telephone (403) 267-1100 facsimile (403) 261-4622 230, 1801 Hollis Street, Halifax, Nova Scotia, Canada B3J 3N4 telephone (902) 420-9084 facsimile (902) 491-2980 905, 235 Water Street, St. John's, Newfoundland, Canada A1C 1B6 telephone (709) 724-4200 facsimile (709) 724-4225 internet home page: www.capp.ca general e-mail: communication@capp.ca

Contents Acknowledgements ................................................................................................... ii


Introduction.....................................................................................................................1 1. General Notes for the Information of Physicians ..............................................................2 1.1 Objectives of the Medical Assessment......................................................................2 1.2 The Offshore Workplace..........................................................................................2 1.3 The Examination.......................................................................................................4 1.4 Assessment of Fitness ..............................................................................................5 1.5 Return to Work Certificate.......................................................................................5 1.6 Frequency of Examination........................................................................................6 1.7 Confidentiality..........................................................................................................6 1.8 Visitors. ...........................................................................................................6 1.9 Documentation.........................................................................................................7 2. Guidelines on Specific Conditions Which May Affect Medical Fitness for Offshore Work 8 2.1 Infectious Diseases...................................................................................................8 2.2 Neurological System................................................................................................8 2.3 Ophthalmologic System............................................................................................8 2.4 Cardiovascular System.............................................................................................9 2.5 Respiratory System..................................................................................................9 2.6 Gastrointestinal System.............................................................................................9 2.7 Genitourinary System.............................................................................................10 2.8 Musculoskeletal System.........................................................................................10 2.9 Endocrine System..................................................................................................10 2.10 Dermatological System...........................................................................................10 2.11 Psychiatric .........................................................................................................10 2.12 General..........................................................................................................11 Addenda ...........................................................................................................................12 1. As per API Recommended Practice 2D Third Edition, June 1, 1995 Recommended Practice for Operation and Maintenance of Offshore Cranes...................................12 2. Division 8 of Transport Canada Crewing and Marine Certification Regulations.........13 3. Medical Examination of Seafarers...........................................................................20 4. Canadian East Coast Offshore Fitness Certificate....................................................22

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Acknowledgements
Thanks to members of the East Coast Occupational Health Advisory Committee consisting of Marilyn Walker, Petro-Canada; Jean Bernier , Mobil; Mary Power, Atlantic Offshore Medical Services; Brenda Baker, Hibernia Management & Development Company Limited; Susan Schafer, Chevron; Carl Robbins, Offshore Health Services Group; Cieran OShea, Atlantic Offshore Medical Services; Arthur Parsons, Atlantic Offshore Medical Associates; and Rod Crutcher, Mobil who volunteered their time and expertise to ensure the completion of the initial version of this guide.

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Introduction With the exception of the introduction, this guideline is intended for the use of physicians completing the medical examination for fitness to work offshore. In order to meet the objectives of this guideline, the operating company must ensure that: All contractors are expected to meet or exceed the operating company's standard. The prospective worker has the required documentation and understands the process to have a medical assessment that complies with this guideline. Examining physicians consult with the Operator's Medical Advisor when issuesrelated to fitness to work are identified (refer to section 2 "Guidelines on Specific Conditions Which May Affect Medical Fitness for Offshore Work").

Operators Medical Advisor (OMA) Role Qualified physician determined by the principal operator to manage the Occupational Health Services System For the purposes of these guidelines the accountabilities of the role of OMA are: (1) Selection of preferred examining physician(s) (2) Final determination of workers fitness to work offshore Preferred Examining Physician Role For the purposes of these guidelines the accountabilities of the role of Preferred Examining Physician are: (1) Understanding of offshore work environment (2) Access and utilize guidelines and medical forms (3) Communicate with OMA on red flags identified on examination. (4) Communicate with OMA recommendations for health management.

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1 1.1

General Notes for the Information of Physicians Objectives of the Medical Assessment

The offshore work site in Canada exists in a remote and potentially hostile environment. Adverse weather may cause delays in medical evacuation, and convert a minor medical problem into a major emergency. In conducting the medical assessment the examining physician is responsible for carefully assessing the physical and mental health of offshore workers, bearing in mind the unique nature of the offshore workplace as well as offshore workers particular job duties. Objectives of the Medical Assessment are: To ensure that designated offshore personnel are medically fit to work safely at an isolated location, with job accommodation where possible. To anticipate and, where possible, prevent the avoidable occurrence of ill health offshore which could place the individual, his or her colleagues and the emergency rescue service at risk. To provide occupational health surveillance, that is, monitoring for specific job demands and to meet any regulatory requirements for hazard monitoring. The Offshore Workplace

1.2

The examining physician must ensure that the medical assessment of a prospective offshore worker relates to the particular work factors and environment of the work site. It should be noted that emergency illness puts others, for example rescuers, coworkers at risk in the event of medical evacuation, particularly in adverse conditions. 1.2.1 Offshore Work Factors

The examining physician should have a thorough knowledge of the following factors, which include, but are not limited to: Physical exertion (climbing walkways, stairs, work tasks, etc.) and exposure to heights; Shift work with long hours, for example twelve-hour shifts, and changes in routine; Absence from home for prolonged periods, up to three weeks; Adverse weather; Helicopter and boat travel, possible basket transfer (crane-suspended transport from installation to vessel along side);

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Smoke, heat and cold exposure; In-water exercises including exit from and entry into water; Confined, close community; Limited privacy; Peer group pressure; and Abstention from alcohol.

1.2.2 The Offshore Environment The Canadian offshore work site is remote and has unique characteristics that set it apart from more familiar shore-based work environments. Physicians assessing offshore workers need to consider the following: The site may be remote from shore-based medical services. Adverse weather conditions may prohibit or delay medical access to or evacuation from the offshore location. The physical structure of an offshore installation, with numerous stairways and ladders, requires a reasonable degree of physical stamina and agility. Emergency situations, including abandonment, may involve the individual being exposed to extremes of physical exertion, to thermal/smoke exposure, as well as cold water immersion and severe sea states. All offshore personnel must undergo training in fire fighting and sea survival and helicopter escape training, which simulate these situations. The physical and mental health of an individual must not cause an additional hazard, whether to the individual or to his or her colleagues, in an emergency situation (for example, fear of flying, fear of confined, closed communities, severe seasickness).

Episodes of ill-health or disability that may be wholly compatible with onshore employment may prevent the individual from working offshore, either temporarily or permanently, where the condition places the affected individual, or his or her colleagues, at risk. As a result, designated offshore personnel are in a special medical category.

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1.3 1.3.1

The Examination The Medical History

The following are mandatory aspects of the medical history: 1.3.2 Proof of the identity of the prospective worker (for example, by passport, drivers licence or similar) should be requested at the time of examination Completion of a comprehensive medical, social and occupational history questionnaire Prospective worker signature on the completed questionnaire verifying that it is a complete and true record, and recognition of the significance of so doing The Assessment

A comprehensive, work-focused history and physical must be performed. Required Investigations Dipstick urinalysis Blood Tests CBC Glucose Creatinine ALT, Alkaline Phosphatase, GGT Baseline audiogram Vision Screening Visual acuity near and far Colour vision ECG age 40 years or older, or with other indications

Required Testing Based on Special Job Categories Crane Operators / Signalman Depth perception

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Peripheral fields (See Addendum 1) Firefighters (primary role) Pulmonary function testing Stress electro-cardiogram (ECG) if over age 30 Food Handlers Stool cultures if having diarrhea Seafarers As outlined in Division 8 of the Transport Canada Crewing and Marine Certification Regulations. For more details, refer to Addendum 2. Further Investigations may be required based on: 1.4 Previous occupational history and health hazard exposure Result(s) of comprehensive history and physical examination Assessment of Fitness

Fitness to work offshore is determined by the medical findings, but the evaluation may be influenced by any of the following: Location of the operating site and the medical services available; Prognosis of any condition and the efficacy or potential side effects of treatment; Risk of relapse or acute exacerbation requiring medical intervention, Any adverse effects which could be precipitated by the offshore environment; The proposed frequency and duration of offshore visits; The availability of special medical support; Age should not be an absolute restriction to fitness to work offshore, but must be taken into account carefully, with all the other findings in the assessment. 1.5 Return to Work Certificate

Following referral or evacuation from an offshore installation, or following any undue delay in return to work for medical reasons, the worker will not return offshore until appropriate medical
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documentation and clearance has been obtained. This may require consultation with the Operators Medical Advisor, such as the case of prolonged absence or serious injury. The operator will have a process in place to evaluate fitness to work of the worker following referral evacuation from an offshore installation, or following any undue delay in return to work for medical reasons. 1.6 Frequency of Examination

Every person is required to have completed an offshore medical assessment prior to employment offshore and thereafter at the following minimum intervals: Up to age 39 years Age 40-49 years Age 50 and over - every 3 years - every 2 years - annually

Individual operators should retain the right to conduct medical assessments on their workforce more frequently as indicated. The Operators Medical Advisor may recommend increasing the frequency of periodic assessments if clinically indicated such as in those persons with chronic, but not disqualifying conditions. In some circumstances, specific vocational testing may be required, for example, depth perception. 1.7 Confidentiality

All information will be treated in confidence in accordance with the Canadian Medical Association (CMA) Code of Medical Ethics and other similar professional ethical standards. 1.8 Visitors

In cases where a visit offshore is arranged at short notice and it is not practicable to arrange a medical examination, the recommendation for visitors should be: OR An approved United Kingdom Offshore Operations Association (UKOOHA) medical certificate from the North Sea is acceptable for visitors, or a similar certificate from Norway. An offshore certificate from other provenance may be considered after careful evaluation of results of physical assessment by OMA. Medical clearance or a medical certificate should be obtained from the visitors physician.

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1.9

Documentation

The medical questionnaire/examination form and Fitness Certificate used by the examining physician should be one recommended and approved by the Operators Medical Advisor. (See Addendum 3 & 4 for examples.) Prior to completion of Certificate of Fitness, the examining physician shall ensure that consultation with the Operators Medical Advisor has taken place when any red flags, as outlined in section 2, have been identified.

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Guidelines on Specific Conditions Which May Affect Medical Fitness for Offshore Work

The following list of medical conditions, which may have serious implications and/or the potential for repeated or frequent relapses, has been compiled as red flags to aid the examining physician in determining situations where consultation with the Operators Medical Advisor must be sought. 2.1 Infectious Diseases

As a result of the isolated and close working environment in the offshore, screening for reportable communicable diseases should be conducted to prevent contamination of the offshore population. 2.2 2.3 Neurological System Epilepsy, seizure disorder, with the last seizure within the past two years Uncontrolled narcolepsy or other disturbances of consciousness without satisfactory explanation and without optimal response to treatment Head injury with concussion syndrome within the past three months Spinal cord or demyelinating disorders which could interfere with safe work performance and emergency installation evacuation Significant nerve entrapment syndromes or neuropathies Frequent, incapacitating migraine or other recurrent severe headache Active or recurrent vertigo or significant dizziness of any etiology History of cerebrovascular disease including cerebrovascular accident(s), and transient ischemic attack(s) Absence of reasonable hearing, with or without hearing aid Ophthalmologic System Color vision deficit posing potential risk in the particular employment to be undertaken. Poorly controlled glaucoma or other ocular conditions. Monocular vision.

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2.4 2.5 2.6

Cardiovascular System History of myocardial ischemia with or without infarct or any evidence of existing organic heart disease. History of coronary artery bypass graft (CABG) surgery, angioplasty or pacemaker implantation. Active congestive heart failure or cardiomyopathy. Hypertension not well controlled on medications or demonstrated end organ damage. Symptomatic peripheral vascular disease. Recent or recurrent deep vein thrombosis. Aneurysm, A-V fistula, decompensated congenital or significant valvular heart disease. Uncontrolled haemorrhagic disorders. Significant haematological disorders. Anti-coagulant therapy. Respiratory System Chronic obstructive lung disease, asthma, emphysema or bronchiectasis, causing restriction in physical ability and capability, or requiring frequent medication adjustment. Recent or recurrent pneumothorax. Active tuberculosis. Gastrointestinal System Active dental infection, including gingivitis and dental abscess. Recurrent biliary colic, cholecystitis Recent or chronic pancreatitis. Chronic liver disease: for example, hepatitis, cirrhosis Inflammatory bowel disease: e.g. Crohns disease or ulcerative colitis. Active peptic ulceration. Inguinal or femoral hernia. Active perianal or pilonidal sinus, fistula or abscess.

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2.7 2.8 2.9 2.10 2.11

Significant surgical procedure within past three months. Significant fecal incontinence of any etiology. Genitourinary System Renal failure - chronic or acute History of nephrolithiasis, including renal colic. Other genitourinary disease causing significant urinary tract symptomatology. Recurrent or disabling gynaecological condition. Urinary incontinence or enuresis. Musculoskeletal System Any deformity, arthropathy / joint problem or amputation that significantly reduces mobility and/or prevents compliance with installation evacuation procedures. History of recurrent gout. History of recurrent back problems (including neck) or back surgery (including neck). Endocrine System Diabetes - insulin dependence or evidence of poor control with oral agents. Active or uncontrolled pituitary, thyroid, parathyroid or adrenal disease. Symptomatic hypoglycemia. Dermatological System Severe contact dermatitis or other dermatological condition (for example, eczema, psoriasis), which may be aggravated by occupational exposures. Communicable skin disease. Psychiatric History of psychotic illness including schizophrenia, paranoid disorder and bipolar major mood disorder. History of untreated, recurrent or intractable unipolar depressive major mood disorder. History of disabling anxiety disorders including generalized anxiety disorder, panic disorder, phobias and obsessive-compulsive disorder.

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2.12

Personality disorders with associated significant interpersonal dysfunction. Regular use of psychotropic drugs, including anxiolytics, mood stabilizers and antipsychotic medications. History of or active chemical or substance abuse. Situational crises and prolonged adult adjustment disorders with potential aggravation by lengthy separations from family. General Body Mass Index (BMI) greater than 30. Pregnancy. Frank malignant disease. Any history of serious allergies or allergic conditions requiring offshore desensitization injections.

NOTE: Any significant medical condition with potential for repeated or frequent relapses.

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Addendum 1 As per API Recommended Practice 2D Third Edition, June 1, 1995 Recommended Practice for Operation and Maintenance of Offshore Cranes Have vision of at least 20/30 Snellen in one eye and 20/50 in the other with or without glasses, and have depth perception Be able to distinguish red, green and yellow, regardless of position of colours, if colour differentiation is required for crane operation Have hearing, with or without a hearing aid, adequate for the specific operation Have no history of a disabling medical condition which may be sufficient reason for disqualification

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Addendum 2 Division 8 of Transport Canada Crewing and Marine Certification Regulations - Medical Examination of Seafarers Interpretation 60. The definitions in this section apply in this Division.

"designated physician" means a physician who is knowledgeable about the work of a seafarer and is designated by the Minister. (mdecin dsign) "physician" means a person who holds a current licence to practise medicine issued by a provincial college of physicians and surgeons. (mdecin) "seafarer" means a person who is employed in any capacity on a ship, but does not include any of the following persons if they are not required to hold a certificate issued under the Marine Certification Regulations: a) b) c) a pilot who is not a member of the complement; a person employed in a port who is not ordinarily employed at sea; or a person who is not employed in the navigation of the ship, is not assigned specific responsibilities affecting the safety of the ship or of other persons on the ship's muster list or similar emergency plan and is i. employed solely in connection with the construction, alteration, repair or testing of the ship or its machinery or equipment,

ii. employed solely in work directly related to the exploration or development of the seabed and its natural resources, or iii. not employed by the owner or person employing the master of the ship. (navigant) "TP 11343" means Transport Canada Standard TP 11343, Medical Examination of Seafarers -- Physician's Guide. (TP 11343) Application 61. (1) Subject to subsection (3), this Division applies to a seafarer who (a) is required by these Regulations to hold a certificate issued under the Marine Certification Regulations and whose most recent certificate is issued under those Regulations; or

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(b) (i) (ii)

is not required to hold a certificate issued under the Marine Certification Regulations and is employed on a ship of 25 tons or more that is a fishing vessel engaged on a fishing voyage, Class I or a fishing voyage, Class II, or a ship that is not a fishing vessel and is engaged on a foreign voyage, a hometrade voyage, Class I, a home-trade voyage, Class II, a home-trade voyage, Class III or an inland waters voyage.

(2)

Subject to subsection (3), the vision and hearing requirements of this Division apply to a seafarer (a) who is employed in any capacity for which a certificate as master, mate or bridge watchman is required by these Regulations; and (b) whose most recent certificate was issued before July 30, 1997.

(3)

The vision and hearing requirements of this Division do not apply to an engineer who began qualifying service on a Canadian ship before July 30, 1997, if the engineer holds a certificate of competency issued before July 30, 2002.

Prohibition from Accepting Seafarer Employment 62. (1) No person shall accept employment as a seafarer on board a ship of 200 tons or more that is making a foreign voyage or a home-trade voyage extending south of the parallel of latitude 3600'N and that is employed in the transportation of cargo or passengers for the purpose of trade, unless the person holds a valid medical certificate issued under this Division. No person shall accept employment as a seafarer on board a fishing vessel of more than 25 tons that is making a fishing voyage, Class I or a fishing voyage, Class II, unless the person holds a valid medical certificate issued under this Division.

(2)

Prohibition from Employing a Seafarer 63. Beginning on July 30, 1999, no person shall employ a person as a seafarer unless the person produces a valid medical certificate issued under this Division, attesting to the person's fitness (a) to perform the duties for which the person is to be employed; and (b) to make the voyage to be engaged in by the ship.

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Application for Examination 64. (1) (2) Every applicant for a medical examination under this Division shall make an application to the appropriate physician referred to in section 65 in the form issued by the Minister. No medical examination shall be considered to have been conducted under this Division unless the application referred to in subsection (1) has been submitted to the physician prior to the examination.

Capacity to Conduct Medical Examination 65. (1) Subject to paragraph (3)(a), only a designated physician may conduct a medical examination and issue a medical certificate under this Division in respect of a seafarer who requires a certificate to perform duties. Any physician may conduct an initial or periodic medical examination under this Division and may issue a medical certificate in respect of a seafarer who does not require a certificate to perform duties. Any physician may conduct a medical examination allowing a seafarer to return to duty after a medical absence of (a) (b) more than 14 days, where the seafarer requires a certificate to perform duties; and any duration, where the seafarer does not require a certificate to perform duties.

(2)

(3)

Medical Examination 66. (1) The physician conducting a medical examination under this Division shall determine whether the seafarer suffers from (a) (b) (c) an impairment that could cause unpredictable loss of consciousness and that cannot be controlled through medication; a disorder that could prevent the seafarer from reacting efficiently, while on watch, in an emergency; a condition that could endanger others, taking into account the confined living conditions on board ship;

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(d) (e) (2)

a condition that is likely to require emergency medical care and that cannot be controlled through medication; or an active psychiatric disorder.

The physician conducting a medical examination under this Division shall ensure that the seafarer has (a) adequate muscle strength to carry a mass of 22 kg; (b) the physical capacity to wear breathing apparatus and life saving equipment; and (c) adequate vision and hearing and the agility and strength to perform the duties of fire fighting, first-aid administration and ship abandonment in an emergency.

(3)

The physician conducting a medical examination under this Division shall ensure that a seafarer who performs the following duties meets the physical requirements set out in the stated clauses of Section II of Part II of TP 11343, namely, the duties of (a) deck department personnel set out in clause 1.2; (b) engineers set out in clause 1.3; or (c) cooks or stewards set out in clause 1.4.

(4)

A medical examination conducted under this Division shall conform to the guidelines and time-period requirements of the following clauses of Section II of Part II of TP 11343: (a) (b) in the case of a seafarer who holds a certificate, clause 2.1; and in the case of a seafarer who does not hold a certificate, clause 2.2.

(5)

Colour vision standards are those set out in Annex A to TP 11343.

Aids to Vision and Hearing 67. A seafarer who is required to use an aid to vision or hearing to meet the requirements of TP 11343 shall (a) (b) use the aid to perform the seafarer's duties on board ship; and in the case of an aid to vision, possess at least two such aids and a copy of the prescription under which they were made, while performing the seafarer's duties.

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Medical Certificates 68. (1) (2) A physician shall, after completing the medical examination of a seafarer under this Division, issue a medical certificate to the seafarer in the form established by the Minister. The physician shall set out in the medical certificate the physician's assessment of the seafarer's suitability as (a) (b) (c) (3) unfit for service at sea; fit for service at sea with limitations; or fit for service at sea without limitations.

A physician who assesses a seafarer as fit for service at sea with limitations shall state those limitations in the seafarer's medical certificate.

Other Medical Certificates 69. The Minister may direct that a medical certificate in a form other than the form established by the Minister, attesting to a seafarer's fitness for service at sea and issued by a marine industry association following a medical examination, be accepted for the purposes of this Division if it complies with the requirements set out in section 70.

Validity of a Medical Certificate 70. (1) Except where a re-examination is required under section 71, and subject to subsections (2) and (3), a medical certificate remains in force beginning on the day of its issuance (a) (b) (c) (2) in the case of a seafarer at least 40 years of age who holds a certificate, for two years; in the case of a seafarer at least 60 years of age who does not hold a certificate, for two years; and in all other cases, for three years.

Where appropriate, taking into account the state of health of the seafarer examined, a physician may issue a medical certificate that specifies a shorter period of validity than the period set out in subsection (1).

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(3)

Where the period of validity of a medical certificate expires in the course of a voyage, the certificate remains in force until the end of the voyage, or until the end of an additional period of three months, whichever occurs first.

Re-examination 71. The Minister may at any time require the re-examination of a seafarer (a) where the Minister has reason to believe that a re-examination is desirable to protect the safety of the ship or of other persons on board the ship; (b) at the request of the seafarer; or (c) at the request of the seafarer's employer, where the employer has grounds to believe that the seafarer's state of health may constitute a risk to the safety of the ship or of other persons on board the ship. Review of a Medical Certificate 72. (1) A seafarer may apply to the Minister for a review by a reviewing physician of a medical certificate issued under this Division that indicates the seafarer to be (a) unfit for service at sea; or (b) fit for service at sea with limitations. (2) The reviewing physician shall be a designated physician. (3) After reviewing a medical certificate and the state of health of the seafarer to whom it was issued, the reviewing physician may direct that further medical examinations be carried out and may stipulate the examinations and the persons or organizations to carry them out. (4) The reviewing physician shall (a) confirm the medical certificate originally issued; or (b) where appropriate, based on further examinations conducted pursuant to subsection (3), issue a new medical certificate in the form issued by the Minister.

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Appeal of a Reviewed Medical Certificate 73. (1) A seafarer who requested a review of a medical certificate may appeal to the Minister for a further review of the case by an appeal board if the medical certificate confirmed or issued by the reviewing physician indicates that the seafarer is (a) (b) (2) (3) unfit for service at sea; or fit for service at sea with limitations.

An application for a review by an appeal board shall be accompanied by a review fee of $25. On appeal by a seafarer pursuant to subsection (1), the Minister shall appoint an appeal board composed of at least (a) (b) (c) a representative of the Minister; a representative proposed by the employer of the seafarer; and a representative proposed by the seafarer.

(4) (5)

Every appeal board shall be assisted in its deliberations by a physician selected from the designated physicians list by the representatives referred to in subsection (3). An appeal board has the same power as a reviewing physician and may (a) (b) confirm the medical certificate issued or confirmed by the reviewing physician; or where appropriate, based on its deliberations, issue a new medical certificate in the form established by the Minister.

(6)

An appeal board shall record its decision and the reasons for it in writing and send a copy of it to the Minister, to the seafarer and to the employer of the seafarer.

Costs of Medical Examinations for Reviews and Appeals 74. The costs of a medical examination conducted as a result of a review under section 72 or an appeal under section 73 shall be borne by the applicant seafarer.

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3. Medical Examination of Fitness for Onshore/Offshore Employment


Name: ____________________ Date of Birth: ____/____/____ Address: ____________________ Position: ____________________ Reason for this exam: hPre-employment 1 hPeriodic 1 hBST 1 hOther 1 ___________________

1.

Family History
Yes No

4.

Medical History
No

Have any immediate blood relatives ever had: 1.1 Diabetes 1.2 Heart disease 1.3 High blood pressure 1.4 Ulcers or bowel problems 1.5 Mental illness 1.6 Asthma 1.7 Epilepsy 1.8 Tuberculosis 1.9 Cancer 1.10 Strokes

Do you or have you ever had or been treated for any of the following medical conditions: Yes 4.1 Asthma, bronchitis, pneumonia, pleurisy, tuberculosis or other lung disease 4.2 Disease of the nose or throat 4.3 Ear disease, loss of balance or dizziness 4.4 Hay fever, allergies and/or severe allergies requiring to carry Epipen or other medication 4.5 Rheumatic fever, heart disease or murmur 4.6 High blood pressure 4.7 Chest pain, angina or palpitations 4.8 Varicose veins or phlebitis 4.9 Bleeding tendency or bruising 4.10 Diabetes, thyroid disease or other glandular disease 4.11 Seizures, fainting or epilepsy 4.12 Head injury or concussion 4.13 Stroke or paralysis 4.14 Severe recurrent headache or migraine 4.15 Loss of or impaired vision or eye disorder

2.

Personal History

2.1 Have you ever been refused employment or life insurance because of your health? 2.2 Have you ever been regularly exposed to toxic chemicals (such as solvents, asbestos etc.) or excessive noise levels? 2.3 Do you smoke? How much per week? 2.4 Do you drink alcohol? How much per week? 2.5 Have you been off work in the past year because of illness or injury? 2.6 Do you suffer from any phobias? 2.7 If so, does this concern: q flying q confined spaces q fire q water q heights q other 2.8 Do you participate in a regular exercise program?

4.16 Psychosis, anxiety, depression or other mental illness 4.17 Stomach, duodenal or peptic ulcer 4.18 Gall bladder disease, jaundice or hepatitis 4.19 Diarrhea or bowel disease 4.20 Kidney disease, kidney stones or bladder disease 4.21 Neurological disorders such as MS 4.22 Skin diseases, rashes, eczema or dermatitis 4.23 Bone or joint disease or injury 4.24 Back or spinal injury or recurrent back pain 4.25 Tropical disease, malaria, dysentery etc. 4.26 Cancer, tumour or growths 4.27 Other operations, serious illnesses or injuries 4.28 (Women) Gynecological disease 4.29 Motion sickness 4.30 Dental disease, toothache 4.31 Weight gain or loss over 10 lbs. in the last year 4.32 Date of last tetanus shot _________________

3.

Medications

3.1 Do you take any medications? 3.2 Are you allergic to or have you ever had an adverse reaction to any medications?

Remarks: Give details of any yes answers in sections 1-4.

Patient's Declaration
I, (name) ____________________________________________ of (address) ____________________________________________ declare that the above statements made by me for the purposes of my medical examination are true and complete. I understand that any false statements shall be considered sufficient grounds to disqualify me from employment. I also understand that this information will be treated as medically confidential and will not be forwarded to non-medical personnel. Results only (i.e. "fitness to work") will be forwarded to hiring unit.
Signed: _____________________________________ Place: ____________________ Date: ______________

Witness: ______________________________

Discussion Notes:

Physician should record discussion with prospective employee of all positive answers in the questionnaire.

Physical Assessment
Name: ________________________ Date of Birth: ________________________ * Indicates item completed at physicians discretion

1.

General
Yes No

10.

Vision

Yes

No

Not Done

1.1 Identity confirmed 1.2 General appearance 1.3 Personal hygiene 1.4 Identifying features 1.5 Sex 1.6 Height

cm; Weight

Kg; BMI

2.

ENT

10.1 Visual fields normal* 10.2 Distant vision normal Uncorrected R eye L eye 10.3 Near vision normal Uncorrected R eye L eye 10.4 Colour vision normal 10.5 Stereoscopic vision normal*

Corrected

Corrected

Yes

No Not Done

2.1 Ear canals, drums normal 2.2 Nose and throat normal 2.3 Teeth and gums satisfactory condition

11.

Laboratory Investigations

3.

Skin

3.1 Rashes, infections, parasites absent 3.2 Lymph nodes normal 3.3 Breasts normal*

4.

Respiratory System

11.1 Bloodwork normal, CBC Creatinine, Alk Phos, ALT, GGT, Glucose 11.2 Urine microscopy normal* 11.3 Stool cultures normal* 11.4 Audiogram normal* 11.5 Chest X-ray normal* 11.6 Spirometry normal* 11.7 EKG normal* 11.8 Stress EKG normal*

4.1 Chest free from scars or deformity 4.2 Chest normal to percussion and auscultation 4.3 Expansion normal Unexpanded ________ cm Expanded __________ cm

Comments on abnormal findings:

5.

Cardiovascular System

5.1 Pulse: ________/min. Normal rhythm, character, volume 5.2 B/P _________/_________ 5.3 Peripheral pulses and circulation normal 5.4 Varicose veins absent 5.5 Heart sounds normal 5.6 Murmur absent

6.

Abdomen, Alimentary System

6.1 Scars, etc. absent 6.2 Shape normal 6.3 Organomegaly absent 6.4 Masses absent 6.5 Hernial orifices intact 6.6 Rectal examination normal*

12.

Risk Assessment

7.

Genitourinary System

7.1 External genitalia normal 7.2 Pelvic examination normal* 7.3 Pap smear normal*

12.1 Family history high risk? 12.2 Lifestyle satisfactory? 12.3 Occupational health hazard exposure (past, present or future?) 12.4 Past significant medical absence from work? 12.5 Special visit required to medic with letter? (attached)

13.

Physicians Opinion

8.

Musculoskeletal System

8.1 Spine normal, full range of movement 8.2 Deformities or scars lim iting movement absent 8.3 Limbs and joints normalfull ROM

13.1 Is the patient fit for work in all climates and conditions as a: 13.2 Fit for participation in survival training? 13.3 If not, is he/she fit for employment with limitations? Specify limitations: 13.4 Is the patient unfit for work temporarily? Specify anticipated period. 13.5 Is the patient unfit for work permanently as a:

9.

Central Nervous System

9.1 Gait normal 9.2 Rombergs negative 9.3 Cerebellar function normal 9.4 Vestibular function normal Nystagmus absent 9.5 PERLA 9.6 Fundi normal 9.7 Cranial nerves intact 9.8 Tone and power normal in all four limbs 9.9 Reflexes normal and bilaterally symmetrical

Follow-up required: (Date) Physicians name: ____________________________________ Signature: __________________________________________ Date: ______________________________________________

Addendum 4

Canadian East Coast Offshore Fitness Certificate


DOB: ______________________________ (DD-MM-YY) POSTAL CODE: _____________________

NAME: ____________________________________

ADDRESS: ___________________________________ EXAMINING PHYSICIANS OPINION: 1.

IS THE INDIVIDUAL FIT FOR EMPLOYMENT OFFSHORE?

__

YES

__

NO

IF NOT, IS THE INDIVIDUAL UNFIT

__
2.

PERMANENTLY?

__ TEMPORARILY? __________________________(DURATION)

IS THE INDIVIDUAL FIT FOR EMPLOYMENT ONSHORE?

__

YES

__

NO

IF NOT, IS THE INDIVIDUAL UNFIT

__
3.

PERMANENTLY?

__

TEMPORARILY? __________________________(DURATION)

IS THE INDIVIDUAL FIT FOR OFFSHORE SAFETY COURSES ?

__

YES

__

NO

IF NOT, IS THE INDIVIDUAL UNFIT

__

PERMANENTLY?

__

TEMPORARILY?__________________________(DURATION)

DATE OF EXAMINATION: _______________________ (DD-MM-YY) SIGNED: _______________________ PHYSICIANS NAME (PRINT): PHYSICIANS ADDRESS: TELEPHONE:

DATE OF EXPIRY: ________________________ (DD-MM-YY) PLACE: ______________________

DATE: :_______________________

________________________________________________________________ ________________________________________________________________

(_____)__________________________________________________________

CONSENT FOR RELEASE OF INFORMATION: I, _______________________________ (NAME), OF ______________________________(ADDRESS) AUTHORIZE DR. ____________________________(NAME OF EXAMINING PHYSICIAN) TO COMMUNICATE THE ABOVE INFORMATION REGARDING MY FINTESS TO (COMPANY NAME) SIGNED: _____________________________ WITNESS: ____________________________ ORIGINAL: HEALTH ADVISOR DATE: _________________ PLACE: ________________________ DATE: _________________ PLACE: ________________________ COPY: EMPLOYEE

__________________________________________________________________________________ Page 22 CAPP Guide - East Coast Medical Assessment May 2001 for Fitness to Work Offshore