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FEDERAL REPUBLIC OF NIGERIA i,

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NIGERIAH MAR:TIfi'IE ADMINISTRATIO}I AHD SAFETY AGEHCY

SEATARER'S MEDIEAL CERTIFICATE

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Ia ORIGINAL

This Certifigrte is issued by the Government of the Federal fiepublic of Nigeria in compliance with the requlrement of Eegulation 1.2 standard
A 1.2 of the-Maritime Labour Convention, 2m6 (Ml-C '!6). as amended and the lnternational Convention on Standards for Training, Certification
and Watch keeping for seafurers (STCW) 78 as amended.

,:strnahe
EfF\0N GivenNames:U$Cru Cf Tt+Om PS CN
Discharge Eook No: SSID NO: Parsport No: i: sex: ru ffi" Ff]
Date of Birth:
Nationatity:
t$t GE{LtflrN
Department:{Tick relevanl boxr!

Engine d Lalerlng L___j -""s-u&sy_"HN,6l-MF*ffi e

: Oth*, {specifV}
Declo rotion of the recognised doctor
iD checked at the point of examination ves M'ruo [] Hearing standards as in STCW A l/9 Yes m LfNo
Visual acuity standards as in STCW Ai/9 ves ff NoI Unaided Hearing satisfactory YesmNoI
Colorvision standards as in STCWA-l/9 ves M ruof] ls there any iimitation or restriction on fitness? Yes l-l No M

Date of last colsur vision test {dd/mm/yy): gcloq [22 Please specify restricli0n.

i ls the seaiar?r free fre,n: ;trv m.erj,.r-ai conciiticn i;keiy ic be aggravated by service at sea or
i to :"r:nCer ihe:eafarrr urtrt icr iL.:ch se rvire or to e*danger the health of other persons Yes [Vf
-2
No Ll
icn!ra;rd?

I have *xarnined the seefarer rlarned above and have found h;mlhgr fit for seafaring as below
I Mtdkal rlda* eaiesaiy{xia,riiiivax br:t}--
,
I Fr:-No Reslricho. 'M
l.--/
ect ta restriction, l l
:, -,-.-,,-_-_.-----,._-

Flt for iaakcut duty

ritff unnt fl unfit l l

USllvlF,lYYYY
: Ixpiry Date of Certificat

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NOTES

prosecution.

To the Employer

Lagos.
N =H
Or by checking the Agency's webpage at:
 . FEDERALREP{'-HTIC OF. }IIGERIA
iUGERIATCI fifiARITIME ADMIilISTRATION AND SAFETY AGEHCY
SEAFARER'S MEDICAL CERTIFICATION APPLICATION FORM
UHDER REGULATIOhI I.2, STANDARD 41.2, CIF ffiL€ ?006
HITASA
A. APPLICANTS BIODATA
EFF[Cd!G- U,bc r$ G rtt.cltflse^)
SURNAME:
- 0THERNAM$$:
GERI
OOt* nt NATIONALITY: *
DATE OF APPLICATION: PLACE OF BTRTI{:

Discharge N0.:
Address:
DEPT, OF SHIP: DECK:I ENGINE: #*U'*O*NG;[f MASTERJSI&TE: il OTI+ER$ $FHEIFY:

B. APPLICANT'S MEnleAL HISTORY iunc!*r $uid*ne* frc,nn a rnedical personnel)

Have you ever had
YES Nor'
,-'- -*1 .
YES NC
(1.) Admissiontohospitalwhatever
reason at all in the past
i.-J !.vJ {i6.) SexuallyTransmittedDiseases
(Gonorrhea, Syphilis, AIDS ciu)
tfm
12} Any surgieal operation fl "-4
l\./l {17.} Any persistent Muscular weakness L -_i VI
(3.) Any aeeident f: i-:/ (18.i Lossofconsciousness fl t-t'
lY)
{4.) Any mentalillness r_:1 ffi (19.) Pain in spine, Back or any Joint n lU

(5.) ,{ny convulsions d

i: {20.} Balance problenn f: w
(6.) Any Ear or Hearing Brobl*rn nd {.21.1 Anal pain or sweliing tf w
(7.) Any persistent Cough tf d i22.1 Restrictedmobility [f w
(S.) Difficulty with breathing or
breathlessness on mild exertion
tf d (23") Exeessive thirst fl d
(9.) Palpitations ,/ {24] A sign-off as sick or a repatriation from a ship? ff W
il tE' (25 ) Excessive weight loss rl L]lI
(10.) High brood pressure n M,
. (26.) An unfit declaration for sea duty? tf d
i11') Chest pain at rest or on

pain
exertion E
fl
Y,
M'
G7.t Sugar in the urine rd
fl d
(12.1 Stomach .
(28.) Your medieal certificate restricted or revoked?
(13.) Anyvomiting fl M
, (29.) To wear contact Lens or Glasses t-Jd
(15.) ui.ine
i30.) To be plaeed on any medieation ff {f,
Any problem passing nW
2. IMMUNIZATI*hI HI$"!'SRY {Have ycu been irnmunized beforc}
IFYE.S.OA'TE
YES NO YES NO |FYES.OATE YES NO IFYESDATE YES-.IIO IF YES DATE

la.ytetanusffiifi (8,) iyphoier Fever [f M : ic,) cholera tj M--:-- (D.] Meninsitis Mtl
-q"-YES NO IFYESDATfr
{E.)Yellow Feverfi/fl {F}Hepatitis tl w
YES
-
NO IF YES DATE
(G.) Tuberculosis

3. SOGIAU FAMILY HI$TORY l,, r-;If-:: ii::i :*kjr: *:i -iji:,tl:* decrare that
IlE N,/'tfre infornnation given above is correct to thc best of my knowledge"
(A.) Do you smoke, Take Alcehal or use drugs? l-l L/ I I consent to the examining doctor to enclose my rnedical information
(8.) Has any member of your family or relative I on the Medieal fitness Cedificate for official purposes {To he signcd
had mental illness, Epilepsy, Blood disorder, 5 Jgl cnly in the presence of exarnining ductcr)
Heart trouble, Hypertension or any other LIM I

disorder (e.g Allergy etc")

I EFpu,I.g t+th.(r T1*r;rl.vt,
(C.) Do you have a medical or other condition not
rnentioned ah,ove? JWI/,+-
YEs No Date
.-; Name o{ Anp!:cant
r
(D") Others
I
I
-:-\u${ i
$igr.:ture
-
cf APPi:t;ni
 NIGERIAN MARITIME ADMINISTRATION AND SAFETY AGENCY

SEAFARER'S MEDICAL EXAMINATION

=,,l$i PHYSICIAN'S EXAMINATION REPORT FOR SEAFARERS
UNDER REGULATION 1.2, STANDARD A1.2, OF MLC 2006
I{IMASA

EFn c N & ubcN & -miurir pSoN Discharge Book No:

(Surname first)

GENERAL EXAMINATION Normal Abnormat

weight: €3'+lqHeisht: \8?cnr Gait
r .,fr f_] [ ,
^ --/ -.- D
*ni.,nr,., 36j0'c Broodpressr-,r4/gq,:$ *,r.*.J!bro
-- priro,, N&
Palpable lmpalpable lf palpable, state region/location
7

SYSTEMIC EXAMINATION (3.) Eyesight

visualAcuity RT LT
Normal.
'W Abnormal
^i'
(1.) centrar Nervous system -l without gtasses 616 at}

Normal Abnormal

(8.) Orodental fV I -_l *^^^.ir,^ D^-*ii,

Negqtive Positive
(10.) Ear, Nose & Throat lV1 t I (s.) Hepatitis B Antigen fr l -l
orptl NA (6.)
oTHERExAMlNATloNSNormalnAbnormal;;,,-l,.,,e."*Ji@",
-
Widal (for catering

(1.) speech (Voice

(7') UrinalysislllJlllJ
communication;l-71 f-l Normar- Abnci/rmar

(2.1 Hearing fu # (8.) cheptX-Rav*iln*P:1 ffi if

.Audiometry fr rr (e) #mnJ*#**g tH''
^t _j

Physician's Name Physician's Signature & Stamp

\zAu Physician's Addressl Telephone No.

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