Annexure IV Medical Certificate for Service at Sea [issued under the Authority of Directorate General of Shipping, Govt. of india under Rule 4 of M.S. (Medical Examination) Rules,2000 as amended) Singh Hrishiraj (Seafarer Name: Last, First, Middle) 28/01/2003 Mate “Date of Birth: (daimamiyyyy) “Gender (WaleiFemale) Indian Passport/ CDC No. ee ald ll | | | | | has been examined by _Dr. Sanjiv Mukherjee, WE/KOL/04/2015 (NameofMedicalExaminer and approval no.) land has been found fit for service at sea in the job ot. Student (@) The hearing and sight of the seafarer concemed, and the colour vision in the case of a seafarer to be employed in capacities where fitness for the work to be performed i liable to be affected by defective colour Vision, ae all satisfactory; and (6) The Seafarer concerned is not suffering from any medical condition likely to be aggravated by service at sea orto render the Seafarer unfit for such service or to endanger the health of other persons on board. (6) The seatarer complies withthe requirements specified in Table A-V9 of STCW Code (1. Minimum in service ‘eyesight standards for seafarers), Table B-/9 of the STCW Code (.c. Assessment of minimum entry level and in- ‘service physical abilties for seafarers) and Regulalion 1.2, Slandard A-t.2 & Guideline B- 1.2 of the Martie Labour Convention 2006, osr1072020 Kolkata, West Bonga, nda Se. (Date & Place of Medical Examination) (Signature of the Medical Examiner) KE0610206: (Gerial number of the Certificate) [Address Maritime Medical Consultancy 11/14, Mancharpukur Road, Kolkata-700026, West India. E-mail 1D 033 2419-2228 / 2186 / 2187 Contact no = ‘mm_c@maritimemedica net Dr. Sanjiv Mukherjee DG$ No. Wa/KOL/o4/2015 Maritime Medical Consultancy His lita-700026 This Certificate expires on* 96/10/2022 Oficiat ste of tH NEUEN Bide ="7°°° (Day, Month, Year)* (¢ Not more than 2 years fom the date of isue, unless the seafarers is under the age of 18. in which case the maximum period ‘of valiy of the Medical Crticate shal be 1 year. the period of vat ofthe medical certiicate expres in the course of ‘voyage, then the medical certificate shall cortinue tobe in force for a period not excecing three moths from the date of expy, ‘runt the nest port of cll where an approved Medical Examiners avaiable, and the Seafarer can get examined and obtain Tervewed medical certcto tom that Medica ExaminerDr. Sanjiv Mukherjee mans. ‘Reg. Ko. 48130 Maritime Medical Consultancy Kona 700026 Ina Phone : (033) 2419-2228 : Fan. (033) 2419-2 Oran Ges ot ge Go na, Regen M.S No.3 Meuiese-oaa.0n0807 2008 (Ceriicate Mo, QACS-A-2258 ‘email: m_m_cOmaritimemedical net SIGHT TEST CERTIFICATE New Entry* / Periodic* Reference No. KE0610206959 Full Name Hrishiraj Singh Rank Student: PP/CDC/D Card No. See Date and Place of Birth 25/01/2008, Assam , India. Colour of Eyes Identification Notes [ Right Eye Unaided ee ee ‘Aided NA NAL Unaided NB. Nie ‘Aided NA NA Horizontal Plane: Vertical Plane ‘Ishihara Lantern / Others Distant Vision Near Vision Field of Vision Colour Vision I, Dr. Sanjiv Mukherjee hereby certify that the above mentioned candidate has met/net met*, the eye sight standard for his/her designated rank /pesitien as set out in Annex-II* /Annex- III* for seafaring occupation Candidate's Signature ‘Signature of DG Approved Medical Fxaminer WB/KOLIO4/2015, Dr. Sanjiv Mukherjee M.B.B.S. Reg. No.-48130 DGS No. WB/KOL/04/2015 06/10/2020 Kolkata, West Benga, a,itime Medical Consultancy TPA, Mogae ond, Kolnt-700 028 Official Sta 4) Tis corticte is vali fortwo years rom he above date, New entry sight tet certfcats should be retained by the candidate til his active sea career. 2) Seafarer aggrieved by the decision of the Medical Examiner may appeal as per the provision of the MS. (Medical Examination) Rules, 2000 as amended. * Delete if not applicable. Note: The principal rules were published in the Gazette of india, Part Il, section 3, sub-section (i) vide ‘Notification Number G.S.R.57 (E) dated the 19" January, 2000.g Maritime Medical Consultancy DrSanjiv Mukherjee Reg No#120 REPORT OF MEDICAL EXAMINATION OF SEAFARER BY AN APPROVED MEDICAL EXAMINER. 80 9001:2008 (Certificate No. QACS-A-1254) ‘As per Merchant Shipping (Medical Examination) Rules, 2000 and ISM/STCW code 1/9 and ILO convention 147, and MLC 2006 compliance Elite Nursing Home Approved by Directorate Genera of Shipping INA Manoharpunur Road, Kokatn. 700 02. ina Name: Singh ‘Suamé Date of Birth: Vessel " 2so12003 Home Address : Ananda nagar,Nabapally,Assam,India. Company Name and Address : Manet pune Medical History any past/ present history any of lowing Severe one skied headaches (Migrane) Head Injury / Concussion / Loss of Memory Fis / Epilepsy] Dizziness / Fainting Eye / Vision Problems (Glasses, etc) Heating Impairment Ear / Nose / Throat problems Stomach / Bowel disorders Gal stones / Kidney disorders Jaundice / Lver Disease Piles / Varicose veins Blood Disorder Female Dsorder Medical Examination Height | Weight in Kgs [Chest Insp Exp Ce ‘Color Vision [Ishihara ‘Other Field of Vision | "Systemic Examination Head & Neck Eyes Ears / Nose / Throat Teeth / Oral Cavity ‘Musculo-Skeletal system Inds No.: 7 Blood Pressure in mm of Ho of nei) as per M.S Notice No.1 of 2016, No. WIKOUDA2015 Ph: (033) 2419-2186 /2187. Fax. (032) 2419-2386 _ e-mail: m_m_c@maritmemedicalnet irishiray First Name idle Namg Pp coc: Phone : 07002296718, Plea anewer the folowing tothe bet of your Knowledge. Candidates | Examiners Dedaration i Hein /Hiydrocoele / Appendicts High / Low blood pressure / Heart disease Asthma / Bronchits / Tuberculosis ‘Alergy / Skin disease Infection / Contagious Disease ‘Addiction to alcohol / drugs / tobacco Fracture / Dislocation / Injury / Amputation Major / Minor Operation Diabetes: Nervous / Mental disease / Sloop disorder Motgnant dense (Cancer) COCCI fi CLEC )¢ KISKSRISKSISSIS) & Pulse Beats / min | Resp.Rate / min | 72 min 167 min Hearing “Right Ear ‘Left Ear 118/80 mmHg Corrected “NIA |N/A | Per abdomen | Genito-urinary system | Gastro Intestinal System Hemia / Hydrocoele Fissure/Fistuia/Ples ‘Lymp 28% Eos 06% Ba 00% Mo 1% | Speciic Gravity. 2.0% 6.0%. 4-15 mm/h ‘Special Investigation Body Mass Index (BM) : BME : 22.2 Gamma GT. ECG. Within Normal Limits On the base ofthe eamince’s history, cinkal examination nd dagncstc ts 1, Dr Mukherjee, hereby dele the examinee medcaly Ft Unt) Remarks ‘MEDICALLY Candidate's Signature | Cert Seamed Sgr Ong inedin rors mines Sb ‘Temporary unfit) ed ee rT | 1 Dr. Sanjiv Mukherjee, certfy that al information requjged und “Certificate valid til 05/40/2022 | M.S. (Medical Examination) Rules 2000 ts incorporat Tssued On: Permanently unft ‘Should be re-examined in rs ne fer Aanexure E8 F ns create, 6/10/2020,Maritime Medical Consultancy Dr. Saniiv Mukherjee AUDIOMETRY REPORT Serial No. KE0510206959 DATE:- 06/10/2020 AGE: 17 years COMPANY:- Manet pune + A> Right Ear ~~ Left Ear -20 10 VALUES 0 Hz [Righter] [Left ear wh Fe) 20 a soo] 35 [aS] 35 30 1k 35 faa} 30 a 15K} 30 fas] 30 40 2x] 30 |p| 25 50 3k} 25 |B] 25 4x} 25 |B] 20 60 ex} 20 |B] 20 70 ek] 20 [a8] _20 80 90 100 110 | -250--800—4k 4.8 2k 3k tk BK 8c 120 —__________.. oo 4 Hearing Threshold level in €® REMARKS:- Within Normal Limits