- Laws of Fiji


		Fiji Government

		Maritime Safety Authority of Fiji

PART A — TO BE COMPLETED BY APPLICANT

You should complete this section before you go for your medical examination.

Personal history

You must take a suitable means of identification (passport, certificate of competency, Fiji driving licence) with you to the examination.

Are you in good health now?

□ Yes

□ No

Name

Do you drink alcohol?

□ Yes

□ No

Family Name

If yes, how much and how often?

Given name(s)

Do you smoke tobacco?

□ Yes

□ No

PIN (MSAF ID No) Date of birth

If no, have you smoked in the past?

□ Yes

□ No

□ Male
□ Female

Have you been absent from work due to sickness or injury for more than 14 consecutive days over past two years? □ Yes □ No

If yes, give details

Permanent address

Position onboard vessel

Have you had any surgical or chiropractic treatment?

□

Deck officer

□

A/B Deck Rating

□ Yes □ No

□

Integrated Rating*

□

Other (eg Entertainer)

If yes, give details

□

Engine Room Rating*

□

Catering*

□

Engineer officer*

□

AB Deck/AB Engine

* Denotes Hepatitis A arrangements to apply

PRIVACY NOTE

Have you now, or have you previously had any of the following:

Please read carefully for information and guidance. The information contained on this form and its associated documents will be used for the purpose of assessing your medical fitness for duty at sea and for MSAF audit purposes. This information may be exchanged between your examining medical officer and your treating recognised medical practitioner and/or any medical panel convened to assess your fitness standard for duty at sea, you and your employer will be advised of this on the Certificate of Medical Fitness.

•

Anxiety or depression

•

Migraine or persistent headaches

•

Epilepsy or fits

•

Poliomyelitis or other paralysis

•

Attack of unconsciousness or weakness, dizziness or turns □ Yes □ No

•

High blood pressure

•

Disease of the heart, arteries or blood vessels

•

Operation on the heart

•

Anaemia or any other disease of the blood

•

Swelling of the ankles

Are you taking any medication at present?

•

Palpitations

•

Varicose veins or abnormal bleeding

□ Yes □ No

•

Rheumatic fever □ Yes □ No

•

Disease of the liver (including jaundice or hepatitis)

Do you have or have you had any eye disorder or injury?

•

Disease or ulcer of the stomach or duodenum

□ Yes □ No

•

Recurrent abdominal pain/persistent indigestion

•

Appendicitis

NOTE: If you wear glasses, corneal or contact lenses, bring them with you to the examination.
CHROMAGEN LENSES MUST NOT BE WORN

•

Gall bladder disease

•

Disease of the bowels

•

Haemorrhoids (piles)

Have you ever been declared unfit for duty at sea?

•

Hernia (rupture)

•

Recent change in weight □ Yes □ No

□ Yes □ No

•

Asthma

•

Bronchitis or emphysema

If yes, state when, for how long and for what reason

•

Tuberculosis

•

Persistent breathlessness

•

Persistent cough

•

Collapsed lung

•

Other lung disease/abnormal x-ray □ Yes □ No

•

Infection of bladder

Has your Certificate of Medical Fitness ever been restricted or cancelled or have you ever been declared unfit?

•

Kidney disease or kidney stone

•

Difficulty in passing urine

•

Any abnormality of the urine

•

Sexually transmitted disease □ Yes □ No

□ Yes □ No

•

Lumbago, sciatica or other back trouble

•

Any form of arthritis or stiff joints

If yes, give details

•

Slipped discs or back or neck pain

•

Joint injuries

•

Injury of the neck or back

•

Repetitive strain injury, tennis elbow, tendonitis

•

Broken bones

•

Gout □ Yes □ No

Have you ever been signed off as sick or repatriated from a ship?

•

Discharge from ears or perforated eardrum

•

Ringing in the ears or disturbances of balance

•

Deafness

□ Yes □ No

•

Nasal or sinus trouble

If yes, give details

•

Persistent husky voice or frequent sore throat

•

Goitre or Thyroid disease □ Yes □ No

•

Any form of cancer or unexplained lumps

Family History

□ Yes □ No

(a)

Has anyone in your close family or household been treated for tuberculosis (TB) in the past ten years? □ Yes □ No

•

Diabetes □ Yes □ No

•

Dermatitis/eczema/skin eruptions

•

Allergy conditions including hay fever

(b)

Do you have any family history of heart disease, arthritis, rheumatism or diabetes?

•

Any abnormality of the immune system

□ Yes □ No

•

Any allergic reaction to any serum, drug or medicine (including anaesthetic agents) and vaccines

(c)

Has anyone in your family ever been treated for mental illness or nervous condition?

□ Yes □ No

•

Any disease such as malaria, typhoid, amoebiasis, giardia, etc.

□ Yes □ No

Provide further information if any of the answers to the above is yes .........................

•

Severe tooth or gum trouble

General

•

Impacted wisdom teeth □ Yes □ No

(a)

Do you wear glasses or corrective (contact) lenses?

•

Any obstetric or gynaecological problems

□ Yes □ No

(b)

When did you last have a chest x-ray (year) .........................

Are you pregnant? □ Yes □ No

(c)

When did you last consult your doctor for an illness? (month and year) .........................

Please give details of any complaint, illness or injury not previously mentioned

If yes, give details

The following should be signed in the presence of the examining medical officer

WARNING: Giving false or misleading information is a serious criminal offence and may lead to prosecution

Are you aware of ANY circumstances regarding your health which may interfere with the satisfactory discharge of the duties of your designated position/occupation?

□ Yes □ No

If yes, give details

Declaration

I hereby declare that, to the best of my knowledge my personal statements are true and correct

Applicant’s signature .........................

Date ........................./........................./.........................

Authority to divulge medical information

If, as a result of this or subsequent examinations for the purposes of assessing my medical fitness for duty at sea, the examining medical officer requires relevant medical details from my treating medical advisor(s), permission is hereby granted to obtain information from:

Dr .........................

Address & phone .........................

(Current General Practitioner)

Dr .........................

Address & phone .........................

Dr .........................

Address & phone .........................

Applicant’s Signature .........................

Date............................................................................/.........................................................................../....................................................................................................

PART B — TO BE COMPLETED BY APPROVED MEDICAL EXAMINER

Date of last colour vision test if not tested at this examination

Medical Examiner’s name

Telephone number

/ /

Applicant’s proof of identity

Does the applicant suffer from any degree of colour blindness as determined by Ishihara plates?

□

Photo driver’s licence

Ishihara test □ Pass □ Further
testing needed

Passport/Driving
Licence No

Show number of plates with errors

□

Passport

Lantern test □ Pass □ Fail □ Not
required

(Deck dept only)

□

Other

Applicant’s position onboard ship

Farnsworth D15 □ Pass □ Fail □ Not required

test (Engine dept only)

SPEECH/HEARING/BALANCE

Note: Requirements regarding hepatitis, colour vision etc will depend on the applicant’s position onboard the ship.

Is there any defect in speech?

□ Yes

□ No

Is there any disease of the ears?

□ Yes

□ No

HEIGHT/WEIGHT

Is there any defect in hearing?

□ Yes

□ No

Romberg’s test normal?

□ Yes

□ No

Height (without shoes) ......................... metres

Pure tone and audiometry (threshold values in dB)

Weight....................................................................................................................................................................................................................................................................................kg

Body Mass Index (BMI) =

Weight in kg

.........................

500Hz

1000Hz

2000Hz

3000Hz

4000Hz

6000Hz

(Height in m)²

Right ear

Left ear

VISION

Conversation Test at 3 metres

Is there any visual effect of the eyes?

Conversation test only required if hearing loss in the better ear is more than 40dB at 500 to 3000 Hz

□ Yes □ No

Speech

The visual acuity of each eye should be tested with Snellen’s Charts and the results recorded:

Both ears together

/10

Visual acuity

CARDIOVASCULAR

Unaided

Aided

Pulse: ............................................................................................................................../min

Rhythm........................................................................................................................................................................................................

Right eye

Left eye

Bino-
cular

Right eye

Left eye

Bino-
cular

Blood Pressure reading: Systolic................................................... Diastolic....................................................

Distant

•

If this reading is above 150/95 please take further readings after rest.

Near

Systolic................................................... Diastolic....................................................

Visual fields to confrontation

Heart sounds/apex beat
□ Normal □ Abnormal

Normal

Defective

Is there any history or evidence of taking anti-hypertensive medication?

□ Yes

□ No

Right eye

Left eye

ECG Report (Attach report and tracing to this form) (Stress ECG required if clinically indicated. Baseline tracing only to be attached to this document.)

Colour Vision

Colour vision need to be tested if a test has been completed within the previous 6 years.

Date of ECG:................................................................................................................................................................................................................................

ECG results

MOUTH/TEETH

Is there any disease or abnormality of the mouth, throat or neck?

□ Yes

□ No

Stress ECG result (if clinically indicated)

Are there any defects in teeth?

□ Yes

□ No

Is there any disease of the nose or sinuses?

□ Yes

□ No

Does the applicant suffer from oedema or varicose veins?

□ Yes

□ No

Details of any abnormalities

If yes, state severity.........................

Are carotid/peripheral pulses normal?

□ Yes

□ No

GASTROINTESTINAL/RENAL

Are you satisfied that the cardiovascular system is clinically within normal limits?

Is there any disease or abnormality of the abdominal organs?

□ Yes

□ No

□ Yes

□ No

If no, give reasons in full

If yes, give details

RESPIRATORY

Trachea

□ Midline

□ Abnormal

Is there any hernia present?

□ No

expansion

□ Abnormal

Is the liver enlarged?

□ Yes

□ No

Breath sounds

□ Normal

□ Abnormal

Urine dipstick results

Glucose

□Normal

□ Abnormal

Protein

□Normal

□ Abnormal

Protein

□Normal

□ Abnormal

Spirometry

Actual

Predicted

%
Predicted

Other .........................

FEV₁

Hepatitis A, previously
vacinated

□ Yes

□ No

FVC

FEV₁/FVC

If yes, date of last vaccination

/ /

Spirometry

FEV₁ < 65% requires further review

If no, results of blood test

□ Antibody positive

FVC < 70% requires review

□ Antibody negative

FEV₁/FVC < 70% requires review

Hepatitis A vaccine

□ Given

□ Not given

Chest X-ray report

□ Normal

Hepatitis arrangements apply to applicants who have a position onboard marked with an * on the front page of this form.

□ Abnormal

(chest x-rays are required for pre-sea medicals or if clinically indicated.)

NEUROLOGICAL/PSYCHIATRIC

Date.........................

Is there any evidence of organic disease of the brain, spinal cord or nerves?

□ Yes

□ No

(Attach report to this form)

If, after examination you are not satisfied with the clinical condition and efficiency of the respiratory system and chest give reasons

Is there any evidence of mental or nervous disorder including psychoses?

□ Yes

□ No

Is there any evidence suggestive of anxiety, panic disorder or personality disorder?

□ Yes

□ No

If no, give reasons in full

ATTACH ALL TEST DOCUMENTS TO THIS REPORT

MUSCULOSKELETAL

• CHEST X-RAY REPORT

Does the applicant have normal use of the legs and arms?

□ Yes

□ No

(for pre-sea medicals or if clinically indicated)

• ECG TRACING

Are there any missing limbs or digits?

□ Yes

□ No

(for applicants aged 55 years of more and/or if clinically indicated)

• ECG REPORT

Is gait normal?

□ Yes

□ No

(confirmed automatic machine report, or report by FRACGP of appropriate specialist)

• STRESS ECG

Are the bones and joints free of any defects?

□ Yes

□ No

(if clinically indicated)

• AUDIOGRAM REPORT

Are joint movements in normal range and pain free?

□ Yes

□ No

(if clinically indicated)

A copy of this report is to be forwarded by the recognised Medical practitioner to MSAF after the examination is completed. The recognised Medical practitioner should retain a copy for record purposes. A copy may be given to the applicant for his/her records.

Any restriction or pain in movement of spine?

□ Yes

□ No

SKIN/LYMPH NODES

Is there any skin disease, including solar keratosis, BCCs, eczema etc?

□ Yes

□ No

Are there any significant scars, ulcers, or enlarged lymph nodes?

□ Yes

□ No

Are there any skin grafts?

□ Yes

□ No

Are there any identifying marks on the skin?

□ Yes

□ No

Medical Examiner of Seamen’s signature

Date