(ILO FORMAT)

Dr. G.V. RAO, M.D. (Gen.)Regd. No. 9375,

Sunita Nursing Home, VISAKHAPATNAM-530 013.
REPORT OF MEDICAL EXAMINATION OF SEAFARERS BY AN APPROVED MEDICAL EXAMINER
As per MerchantShipping(MedicalExamination) Rules,2010&ISM/STCWCode /9and MLCConvention2006
(A Rhha Serial No G9 Ss
Name
Sumame pta2 First Name Middle Initial

Date of Birth 2 Rank Sex Ma

Passport/CDC No. SLLs- Vessel/ Type :MV ASHOKIAULkAREIEROute :
Address

Company Name
MEDICAL HISTORY Please answer the following to the best of your knowledge.
Is there any past present history Candidates Examiners
Record
Candidates Examiners
of any of these Declaration Declaration
Yes No Yes No Yes No Yes No
Severe one-sided headache (Migraine) No
No Hernia/ Hydrocele I Appendicitis NO No

Head Injury/ Concussion No No High/Low blood pressure Heart Disease No No

Fits Epilepsy DizzinessFainting No No Asthma / Bronchitis / Tuberculosis
No No
ye / Vision Problems (Glasses,etc) NO NoAllergy/Skin Disease No
No
No Infection / Contagious Disease No
Hearing impairment NO
No
| Ear / Nose / Throat Problems No
No Addiction toalcohol/drugs/tobacco No
No
Stomach/ Boweldisorders No No Fracture/Dislocation / Injury No No
No Major / Minor Operations
Gall Stones/ Kidney Disorders NO
No NO

Jaundice/Liver Disease NO
No Diabetes No No
Piles /Varicose Veins No No Nervous / Mental illness No No

BloodDisorder NO Malignant Disease (Cancer) No NO

Female Disorder No No Sgned oft on medical grounds/ Declared Unfit| No
NO
Notes
MEDICAL EXAMINATION
Height cm VWeightin Kgs Blood Pressure in mm of Hg. Pulse..Beats/min Resp. rate / min General Conditionn

l2 Healthy
Distant Vision |Uncorrected Corrected | Hearing Normal Voice
Whispered Voice
Right Eye 6lc Right Ear Normal NAD NAD

Left Eye G Left Ear Normal NAD NAD

Colour Vision Normal |Auditometryy kHz 500 1000 2000 3000 4000 5000
Normal dB As per Audiometry Report attached.
Field of Vision Normal |Right Ear
eftEar Normal dB
Notes
ystemic Exam Normal Abnormal Notes Normal Abnormal
| Head & Neck
NAD Respiratory System YES
Eyes NAD Cardiovascular System YES
Ears/Nose/Throat NAD Per Abdomen YES
Teeth/Oral Cavity NAD Genito-urinary system YES

Musculo-Skeletal NAD Others YES

Hernia No
Nervous System NAD

Reflexes NAD Hydroce No

Fissure/ Fistula / Piles No

Skin NAD
Investigations
BLOOD URINE OTHERS
OUR YELLOW E.C.G. NORMAL
HB%
1 & 7
S.G NORMAL

PH ACIDIC x-RAY CHEST NORMAL

DC NL L2 E M)
ALBUMIN ABSENT

SUGAR ABSENT DRUGS AND ALCOHOL NEGATIVE

ESR
AICROSCOPIC NORMAL
Result of Medical Examination
On the basis of the examinee's history, clinical examination and diagnostic test, I, hereby declare the examinee medically

FIT UNFIT NA TEMP UNFIT|NA| PERMANENTLY UNFIT NA

Should be re-examined in days/ weeks/ months

REMARKS/RECOMMENDATION FIT FOR SEA SERV E

CERTIFY THAT ALL INFORMATIiON REQUIRED UNDER ANNEXURE 'E' &'F° OF MS (MEDICAL EXAMINATION) RULES, 2000 ARE INCORPORATED IN THIS

MEDICAL CERTIFICATE
nis certified that the seafarer concerned is not suffering from any medicalconditionlikely to be aggravated by senvice at sea or to
render the seafarer unfit for such service or to endanger the health of other persons onboard.

Issue date 88e2o Dr. G. V. RAO

S
2 8. lo2 Candidate's Signature tam
officiar Stamp Gen)
Valid till
Doerors saye
Email drgvrao51@yahoo co in drgvrao51@gmail comm

P-13
 Dr. GV. Rao, M.D. (Gen)
Marine Medical Consultant (DG
Sunita Nursing Home,
Shipping Approved)
Visakhapatnam
530 013 -

NAME ps.k..iostahad DATE 2 8 . wrv

RANK
LABNo..
AGE/D.0.B. ..S.2..f.3Q...

ANALYSIS OF DRUGS OF ABUSE & ALCOHOL (QUANTITATIVE)

TEST CUT OFF VALUE RESULTS

THC/MARUUANA (Urine) 50 ngm/ml Negative Pesitive
OPIATES (MORPHINE) (Urine) 300 ngm/ml Negative/ Positive
COCCAINE (Urine) 300 ngm/ml Negative/Positire
AMPHETAMINE (Urine) 1000 ngm/ml Negative/Positive
BARBTURATES (Urine) 300 ngm/ml Negative/ Positivé
Alcohol (Urine) 100 mg% Negative/ Positive

The cut-off values are based on the recommendations of N.ID.A. & S.A.M.H.K.A. (U.S.A.).
Note: A Positive result indicates only the presence of the metabolite above the cut off value. It
does not indicate or measure intoxication.

The urine analysis for the above are done by any one of the following available assay
methods
IMMUNOMETRIC ASSAY (RAPID-CHROMATOGRAPHY)
FPIA (FLUORESCENE POLARISATION IMUNO ASSAY)
ELISA
RIA (RADIO IMMUNO ASSAY)
Alcohol test is done by cnzymatic method on Auto-analyzer or breath test of saliva test.

Lab Technologist (Lab Paykologist)

VRAO
Paci.o.9175, MC (Gen)
D. proval No.
2.015
Sunita UrEind
 Appendix -Y

Medical Certificate for Service at Sea

CuntaAsLLaname) First nam and Middle

(Seafarer's Last Namë,
D12 2 ) 31

(Number of: CDC/Passport/other valid identification document with type of document)

has been examined by ACA

(Name of Medical Examiner)

and has been found fit for service at sea in the job of

and the colour vision in the case of a seafarer to be

(a) The hearing and sight of the seafarer concerned,
is liable to be affected by defec-
employed in capacities where fitness for the work to be performed
tive colour vision, are all satisfactory, and

from any medical condition likely to be aggravated by

suffering
(b) The seafarer concerned is not
health of other
service at sea or to render the seafarer unfit for such service or to endanger the
persons on board.

A-I/9 of STCW Code (i.e. Mini

(c) The Seafarer complies with the requirements specified in Table
Table B-1/9 of the STCW Code (i.e. Assessment
mum in service eyesight standards for seafarers).
abilities for seafarers) and Regulation 1.2, Standard
ofminimum entry level and in-service physical Convention 2006.
A-1.2 & Guideline B-1.2 of the Maritime Labour

&w20
(Date&Place of Medical Examination)
(Signdture of the Medical Examiner)
RAO

(Serial number of the Certificate)

Ji11, 1 3

(Address with E-mail ID & Contact No.

of Medical Examiner)

2 8. 2 o 2
Official Stamp of the Medical Examiner
This Certificate expires on *_
(Day, Month, Year)*
of 18, in which case the maximum period of validity of the
unless the seafarers, is under the age
("Not more than 2 years from the date of issue,
Medical Certificate shall be 1 year).
course of voyage, the medical
certificate
medical certificate expires in the
If the period of validity of the Medical Examiner is available and the
the next port of call where an approved
shall continue in force until exceed 3 months.
that period of suchfextension shall not
seafarer can obtain a medical certificate, provided
 Appendix - V

SIGHT TEST CERTIFICATE

New Entry/ Standard*

Reference No.

Full Name uAta ALKLan

Rank 2
PP/CDC/AD card No.
Date and place of Birth

Colour of eyes
Identification Notes

Both Eye Results

Right Eye Left Eye

Unaided
Distant Vision
Aided
Unaided
Near Vision
Aided
Horizontal Plane N
Field of vision
Vertical Plane N
Ishihara M
Colour Vision
Lantern / others

hereby certify that the above mentioned candidate

yCV. A
standards for his / her designated rank / position as set out in STCWA. 1/9-1
has met/ porTmer the eye sight
and CIE 143-2001 for seafaring occupation.

#(Delete the statements if applicable)

not
vision
He/ She be examined at any time with aids to
1) may
be examined after a lapse of one month
2) He / She may of the Chief Examiner.
re-examined again without prior approval
3) He She may not be

Medical Examiner
Candidate's Signature
Signature of DG approved and Mates, MMD
or Examiner of Masters

GV. . RAO
Dated 202t 273 D (Gen)
10

1C313

Note:
should be
above date. New entry sight test certificates
This certificate is valid for two years from the
candildate till his active sea career.
retained by the
this application shall
further advise in case of periodical eye
sight test, one copy of
If failed or to be referred for Examiner of Masters and Mates with detailed report.
Marine Department/Chief
be forwarded to the Mercantile

Where not examined indicate by stating N/E. and colour vision only.
candidates to test for distant
Examiner of master and mates will subject
Delete if not applicable