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Airports Authority of India MARC– Part 5

AMENDMENT/CORRIGENDA RECORDS

The amendments listed below have been incorporated into this copy of the Manual of ATS
Personnel Ratings and Certification-Part 5- Class 3 Medical Assessment

Amd/Corr Subject Source Sections Entered by Approved Effective

No. affected (Date) by date
(Date)
Amd- Revision in Amendment Annexure 1 BS K V Murali 08 Sep
2 Annexure 1 Bhadauria, ED (CAP) 2017
08 Sep 08 Sep
2017 2017

Corr-1 Change in Footer Corrigenda Footer of Kanhaya K V Murali 27 Sep

Form- Lal, ED (CAP) 2017
CAP05/002 27 Sep 27 Sep
2017 2017

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 MEDICAL IN CONFIDENCE Form: CAP-05/001

Annexure 1 to MARC-Part 5

AIRPORTS AUTHORITY OF INDIA

DIRECTORATE OF CERTIFICATION OF ATS PERSONNEL

PART A: SELF DECLARATION FORM

Medical Examination Name of DME: Date (dd/mmm/yyyy):

(e.g. : 01/Jul/2017)
Initial □ Renewal □
1. NAME: 2. GENDER: 4. PHONE NO.:

3. DESIGNATION: M □ F □ O □
5. EMAIL: 6. PLACE OF BIRTH:

7. DATE OF BIRTH (DD/MMM/YYYY): 8. AGE: 9. LAST MEDICAL EXAMINATION

DATE: PLACE:

9A Whether medical assessment has previously been refused, revoked or suspended: YES □ NO □
If yes, the reason for such refusal, revocation or suspension:

10. NAME AND ADDRESS OF OWN MEDICAL PRACTITIONER TELEPHONE NO.

11. EMAIL ID OWN MEDICAL PRACTITIONER:

12. List ALL MEDICATIONS CURRENTLY TAKEN whether prescribed by a doctor or over-the-counter. (Please
indicate vitamins, supplements and herbal medicines)

Name (Generic) Dose Date started Purpose By Whom Prescribed

(a)

(b)

(c)

(d)

8 September 2017 ED/CAP/2017/V1.0-MARC-PRT 5 ANNX-1/ Page 1 of 10

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13. Do you smoke? YES □ NO □ 14. Do you consume Alcoholic drinks? YES □ NO □
If yes, Number of Cigarettes per day: If yes, State Alcohol intake in units per week (One unit is 30 ml)

15. Since last medical, have you had any illness, accident, admission to hospital or started long term medication?
YES □ NO □ If ‘YES’ describe (if require you may attach an additional sheet)

16. MEDICAL HISTORY – Have you EVER had any of the following? Please tick YES or NO. If ‘YES’ describe
in the ‘REMARKS’ column (if require you may attach an additional sheet)

YES NO REMARKS
(a) Eye disorders, eye surgery including
refractive surgery

(b) Ear disease or deafness

(c) Motion sickness requiring medication

(d) Hay fever or allergy

(e) Frequent , severe headaches or Migraine

(f) Dizziness, fainting or unconsciousness

(g) Epilepsy or fits

(h) Head injury or concussion

(i) Insomnia , Sleep walking or Sleep apnea

(j) Psychiatric or nervous trouble of any sort

(k) Asthma or other lung disorder or Chronic

lungs disease (COPD)

(l) Heart trouble or high/low blood pressure

(m) Anaemia or other blood disorder

(n) Stomach, liver or intestinal disorder

8 September 2017 ED/CAP/2017/V1.0-MARC-PRT 5 ANNX-1/ Page 2 of 10

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(o) Diabetes, thyroid or other hormone disease

(p) Sugar or protein in urine

(q) Kidney stone or blood in the urine

(r) Musculo-skeletal disorder

(s) Malaria or other tropical disease

(t) A positive HIV test

(u) Alcohol/substance abuse or related

problem

(v) Chronic illness-TB, Leprosy, VD or

malignancy

(w) Any other illness or injury

(x) Use of opioids, cannabinoids, sedatives,

cocaine, hallucinogens, solvents,
recreational drugs or other psychoactive
substances

(y) Admission to hospital overnight

17. Have you EVER been? Please tick YES or NO. If ‘YES’ describe in the ‘REMARKS’ column (if require you
may attach an additional sheet)

YES NO REMARKS
(a) Refused life insurance

(b) Denied, deferred or delayed in an

application or renewal of an aviation
medical certificate by any licensing
authority

18. Have you any family history of the following? Please tick YES or NO. If ‘YES’ describe in the ‘REMARKS’
column (if require you may attach an additional sheet)

YES NO REMARKS
(a) Heart disease

(b) High/Low blood pressure

8 September 2017 ED/CAP/2017/V1.0-MARC-PRT 5 ANNX-1/ Page 3 of 10

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 MEDICAL IN CONFIDENCE Form: CAP-05/001

(c) Epilepsy

(d) Mental illness

(e) Diabetes

19. Female personnel only: Please tick YES or NO. If ‘YES’ describe in the ‘REMARKS’ column (if require you may
attach an additional sheet)

YES NO REMARKS
(a) Are you pregnant?
If Yes, which trimester/weeks

(b) Have you had a history of gynecological

problems?

(c) Any Menstrual abnormality?

(d) Are you taking any treatment?

If yes, state for what condition
20. Declaration I hereby declare that I have carefully considered the statements made above and that to the best of my
belief they are complete and correct and that I have not withheld any relevant information or made any misleading
statement. I understand that if I have, with intent to deceive, made any false representation for the purpose of
procuring for myself a medical certificate, I may be guilty of a disciplinary action.

Signed by applicant………………………… Date (dd/mmm/yyyy)………….

21. REMARKS – by Designated Medical Examiner:

Signature of DME…………………………………… DME Stamp

DME Name …………………………………

Telephone No.(s)……………………………

DME’s Email…………………………………………………………….

DME’s Address…………………………………………………………………………………………

8 September 2017 ED/CAP/2017/V1.0-MARC-PRT 5 ANNX-1/ Page 4 of 10

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 MEDICAL IN CONFIDENCE Form: CAP-05/001

PART B - REPORT OF MEDICAL EXAMINATION

22. Height (cm) 23.Weight (kg) 24. 25. 26. Identifying Marks, Scars, Tattoos,
BMI Deformities
a) Waist Measurement
1st
________________ cm

b) Chest

27. Hair colour 28. Eye colour 29. 2rd(if indicated)

Insp _________ cm
Pulse
Exp __________cm

30. Blood pressure 31. Temperature 32. Respiratory rate

Please tick for each item. Normal Abnormal Comments: Any abnormal finding should
be given in details. Attach additional
sheet(s) if required mentioning the item
number
33. Head & Neck

34. Mouth Throat Teeth

35. Sinuses Nose

36. Ears Drums Valsalva

37. Respiratory System

38. Heart Size, Auscultation

39. Vascular System Varicose Veins

40. Abdomen, Hernia

41. Liver Spleen

42. Anus Rectum (Only if indicated)

43. Genito-urinary System

44. Endocrine System

45. Upper, Lower Limbs Joints

8 September 2017 ED/CAP/2017/V1.0-MARC-PRT 5 ANNX-1/ Page 5 of 10

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 MEDICAL IN CONFIDENCE Form: CAP-05/001

46. Spine, Spinal Movement

47. Neurological (Reflexes, Equilibrium, etc.)

48. Skin

49. Psychiatric & Mental Status

50. Pelvic Examination (Female only)

51. Breast Examination (Female only)

52. Last Menstruation Date (Female only)

(dd/mmm/yyyy)

53. EYE EXAMINATION

Please tick for each item. Normal Abnormal Comments: Any abnormal finding should
be given in details. Attach additional
sheet(s) if required mentioning the item
number
(a) Lids and Orbits

(b) Visual fields by confrontation

(c) Ocular Movements, Nystagmus

54. VISUAL ACUITY

Right Left Binocular

Without
Glasses
Distant Vision (Standard Test Types)
With
Glasses

Without
Near Vision (N type at 30 to 50 cm) Glasses

[Able to read N5 in the range 30 to 50 cm] With

Glasses

Without
Accommodation in cm Glasses

(Near point 30 cm with or without lenses) With

Glasses

8 September 2017 ED/CAP/2017/V1.0-MARC-PRT 5 ANNX-1/ Page 6 of 10

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 MEDICAL IN CONFIDENCE Form: CAP-05/001

55. Measure of Heterophoria Exophoria Esophoria Hyperphoria 56. Convergence in cm

(a) Result of cover test

(b) By Maddox Rod at 6 m

Number
57. COLOUR PERCEPTION (Initial medical examination only) Correct Number Incorrect

Tested by pseudo isochromatic (Ishihara) plates - State number of correct

and incorrect plates

Tested by an approved Colour Perception Books (Ishihara or Tokyo Medical

College charts) Please tick.
CP II □ CP III □ CP IV □

State name of test and result Pass □ Fail □

58. EAR, NOSE AND THROAT EXAMINATION

Please tick for each item. Normal Abnormal Comments: Any abnormal finding should
be given in details. Attach additional
sheet(s) if required mentioning the item
number

(a) Mouth Throat

(b) Teeth and Gums

(c) Sinuses Nose

(d) Ears Drums Valsalva

59. AUDITORY ACUITY

Any hearing difficulty with Conversational voice at 2 meters with back to examiner? YES □ NO □
At what distance from examiner can Forced Whisper be heard in each ear separately?

Right:……………………. cm Left: ……………………. cm

Rinne’s test: ……………….. Weber’s test: ………………..

8 September 2017 ED/CAP/2017/V1.0-MARC-PRT 5 ANNX-1/ Page 7 of 10

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 MEDICAL IN CONFIDENCE Form: CAP-05/001

60. AUDIOMETRY

Max Remarks
Permitted
Frequency Right Left Loss

3000 50

2000 35

1000 35

500 35

61. ECG Report (Initial exam and when applicable)

62. CXR Report (Initial exam and when applicable)

63. USG Abdomen & Pelvis ( when applicable)

NOTE: ECG tracing and report, CXR report, USG Abdomen & Pelvis should be signed by respective Medical specialist or
Radiologist. ENT Specialist and ophthalmologist report should be attached to this medical report. (Original Copy)

64. INVESTIGATIONS

(a) Blood Routine Hb % TLC DLC

(b) Urinalysis Albumin ………. Sugar ………. Blood ………. Other ……….

(c) Blood Sugar (d) Lipid Profile (e) S. Creatinine…………. (f) LFT or any Other test

Blood Urea…………….

65. HIV TEST RESULTS (initial medical and when indicated) Remarks:

TEST USED: RESULT:

66. Date of last Special Examinations (dd/mmm/yyyy)

ECG Remarks

Audio

Ophthalmologic

8 September 2017 ED/CAP/2017/V1.0-MARC-PRT 5 ANNX-1/ Page 8 of 10

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 MEDICAL IN CONFIDENCE Form: CAP-05/001

67. Comments - Additional comments from DME on Items 12-19 and 22-65, including any items answered YES in
Items 15-19 and your recommendations for further progress reports and specialist consultations:

DME's Overall Comment:

The applicant is found medically Fit / Unfit in Class 3 Medical Examination.

Forwarded to the Medical Assessor, Airports Authority of India, New Delhi for final Class 3 Medical
Assessment

68. Medical Examiners declaration:

I hereby certify that I have personally examined the applicant named on this medical examination report and that
this report with any attachments embodies my findings completely and correctly.

……………………… …….……………………… ………………………

Signature of DME NAME IN BLOCK CAPITALS Date (dd/mmm/yyyy)

8 September 2017 ED/CAP/2017/V1.0-MARC-PRT 5 ANNX-1/ Page 9 of 10

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 MEDICAL IN CONFIDENCE Form: CAP-05/001

69. Medical Assessment issued: YES □ NO □

Remarks:

Date of next due (dd/mmm/yyyy):

 ECG ……….
 AUDIO……….
 OPH ……….
 Any specialist opinion/treatment required…

Date of Validity of Class 3 Medical Assessment (dd/mmm/yyyy):

Signature of Medical Assessor: ……………………………………………

Date: …………………….

8 September 2017 ED/CAP/2017/V1.0-MARC-PRT 5 ANNX-1/ Page 10 of 10

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 MEDICAL IN CONFIDENCE Form: CAP-05/001

Appendix 1 to Form CAP-05/001

List of Investigations to be carried out for Class 3 Medical Examinations

S.No. INVESTIGATION PERIODICITY

1. Blood Hb %, TLC & DLC Every Medical Examination

2. Urine RE,ME & Sp Gravity Every Medical Examination

3. ECG Resting Every Medical Examination (To be opined by Medical / Aviation

Medical Specialist)

4. a) Blood Sugar(F) Every Medical Examination up to 39 yrs of age

b) Blood Sugar(F&PP) At Initial, every medical the moment one has passed 40 yrs of age

5. Blood Urea, Serum Creatinine Every Medical Examination

6. Lipid Profile At Initial, the moment one has passed 40 yrs of age and 50 yrs ,
subsequently once in 2 yrs after 50 yrs of age.
7. LFT At Initial, the moment one has passed 40 yrs of age and 50 yrs ,
subsequently once in 2 yrs after 50 yrs of age
8. CXR At Initial Medical Examination
9. Ophthalmic Examination Every Medical Examination by Eye Specialist

10. Audiometry (Pure Tone) Every Medical Examination up to the age of 50 years subsequently
every alternate medical examination (once in 2 yrs) opined by ENT
specialist
11. HIV Initial Medical Examination

12. USG Abdomen and pelvis At Initial, at the moment one has passed 40 yrs of age and 50 yrs ,
subsequently once in 2 yrs after 50 yrs of age
Note: - For Female ATCO’s Gynaecologist opinion required with every Medical Examination

Periodicity of Medicals

1. Initial (at the time of entry)

2. Renewal:-

Age Periodicity

a) ATCO who have not passed 40th Birthday Every 4th year

b) ATCO who have passed their 40th Birthday but not Every 2nd year
have passed their 50th birthday

c) ATCO who have passed their 50th birthday Every year

8 September 2017 ED/CAP/2017/V1.0-MARC-PRT 5 ANNX-1/ APP-1/Page 1 of 1

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 MEDICA
AL IN CONF
FIDENCE Form
m: CAP-055/001

A
Appendix 2 to Form CAP-05/00
C 01

AIR
RPORTS AUTHORI
A TY OF IN
NDIA

DIREC
CTORATE
E OF CERT
TIFICATIION OF AT
TS PERSO
ONNEL

(DME CERTIFIC
CATE)
Tear off here

Name: Date of Birtth:

Designaation: Employee Number:

N

Addresss:

The appplicant is found

f mediically Fit / Unfit in Cllass 3 Medical Examinnation subjject
to finaal Class 3 Medical
M Asssessment by the Mediical Assessoor, Airportss Authorityy of
India, New Delhii.
Tear off here

…………
……………… …….…………
………………
… ………
…………………

Signatuure of DME NAME IN

N BLOCK CA
APITALS Date

Seal of DME
Tear Off here

Note: To be handed ovver to individuual air traffic controller

c

8 Septem
mber 2017 ED/C
CAP/2017/V11.0-MARC-P
PRT 5 ANNX-1/ APP-2
A Page 1 of 1
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 Form: CAP-05/002
ANNEXURE 2 to MARC-Part 5

AIRPORTS AUTHORITY OF INDIA

CLASS 3 MEDICAL ASSESSMENT

Name Employee No.

Designation
Date of Birth Sex Present Place of posting

Male Female

This is to certify that the Ms/Mr ……………………………………………………….meets the medical

standards prescribed in Manual of ATS personnel ratings and Certification- Part 5 prescribed for Class
3 Medical Assessment.
LIMITATIONS

Date of Medical examination (DD/MMM/YYYY) Valid Until (DD/MMM/YYYY)

Signature of Medical Assessor Stamp

Note: Please bring this Certificate on next Medical Examination

27 September 2017 ED/CAP/2017/V1.0-MARCPRT-5 Page 1/1

Corr-1
 Form: CAP-05/003

Annexure 3 to MARC-Part 5

DIRECTOATE OF CERTIFICATION OF ATS PERSONNEL

NOTIFICATION OF DENIAL OF CLASS 3 MEDICAL CERTIFICATE

Name: Date of Birth: CAP Directorate Reference

Number:

Designation: Employee Number

Address:

Medical Examination Date:

Disqualifying Conditions:

Assessment of your application form and medical examination of above date indicates that you do not
meet the Class 3 Requirements referred to above for a medical certificate, because of the condition(s)
stated. Accordingly, your application for a Class 3 medical certificate is hereby denied.

You may, if you wish, apply to have this decision reviewed. You should apply in writing to the
Chairman, Airports Authority through ATS Incharge / HOD of your place of posting.

Signature of Medical Assessor

Seal of Medical Assessor

01 September 2017 ED/CAP/2017/V1.0-MARC-PRT5 Page 1/1