Fillable - Annex 2 RLM 105M Rev.11 2012

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- Annex 2 RLM 105M Rev.11 2012

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PHYSICAL EXAMINATION REPORT/CERTIFICATE
DEPUTY COMMISSIONER OF MARITIME AFFAIRS
ANNEX 2
THE REPUBLIC OF LIBERIA
LAST NAME OF APPLICANT FIRST NAME MIDDLE
INITIAL
DATE OF BIRTH PLACE OF BIRTH SEX
MONTH DAY YEAR CITY COUNTRY MALE FEMALE
EXAMINATION FOR DUTY AS:
MASTER
RATING
MATE
MOU DECK
ENGINEER
MOU ENGINE
RADIO OFF
SUPERNUMERARY
MAILING ADDRESS OF APPLICANT:
MEDICAL EXAMINATION (SEE REVERSE SIDE FOR MEDICAL REQUIREMENTS) STATE DETAILS ON REVERSE SIDE
HEIGHT WEIGHT BLOOD PRESSURE PULSE RESPIRATION GENERAL APPEARANCE
VISION: RIGHT EYE LEFT EYE
WITHOUT GLASSES __________ / _________
WITH GLASSES __________ / _________
HEARING:
RT. EAR _______________ LEFT EAR _______________
COLOR TEST TYPE: BOOK ¨ LANTERN ¨ CHECK IF COLOR TEST IS NORMAL YELLOW ___ RED ___ GREEN ___ BLUE ___
HEAD AND NECK
HEART (CARDIOVASCULAR)
LUNGS
SPEECH (DECK/NAVIGATIONAL OFFICER AND RADIO OFFICER)
IS SPEECH UNIMPAIRED FOR NORMAL VOICE COMMUNICATION?
EXTREMITIES:
UPPER ______________________________________________ LO
WER ___________________________________________
IS APPLICANT SUFFERING FROM ANY DISEASE LIKELY TO BE AGGRAVATED BY, OR TO RENDER HIM UNFIT FOR SERVICE AT SEA OR LIKELY
TO ENDANGER THE HEALTH OF OTHER PERSONS ON BOARD?
_______________________________________________________ ______________________________________________
SIGNATURE OF APPLICANT DATE
THIS
SIG
NATURE SHOULD BE AFFIXED IN THE PRESENCE OF THE EXAMINING PHYSICIAN.
THIS IS TO CERTIFY THAT A PHYSICAL EXAMINATION WAS GIVEN TO ____________________________________________________________
(NAME OF APPLICANT)
(HE) (SHE) IS FOUND TO BE (FIT) (NOT FIT) FOR DUTY AS A: (MASTER, MATE, ENGINEER, RADIO OFFICER, RATING, MOU DECK, MOU ENGINE or
SUPERNUMERARY).
NAME AND DEGREE OF PHYSICIAN ______________________________________________________________________________________________
ADDRESS ____________________________________________________________________________________________________________________________
NAME OF PHYSICIAN'S CERTIFICATING AUTHORITY __________________________________________________________________________
DATE OF ISSUE OF PHYSICIAN'S CERTIFICATE
__________________________________________________________________________________
SIGNATURE OF PHYSICIAN _______________________________________________ DATE OF EXAMINATION: ___________________
This certificate is issu ed by authority of the Dep uty Commissioner of Maritime Affairs, R.L. and in compliance with the
requirements of the Maritime Labour Convention, 2006 for the Medical Examination of Seafarers.
The Medical Certificate shall be valid for no more than two (2) years from the date of the Ex amination
for those over 18
years of age and for no more than one (1) year for those under 18 years of age.
RLM-l05M (REV. 11/12)
1
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MEDICAL REQUIREMENT
All applicants for an officer certificate, Seafarer's Identification and Record Book o r certification of special
qualifications shall be required to have a physical examination reported on this Medical Form completed by a
certificated physician. T he completed medical form must accompany the application for of ficer certificate,
application for seafarer's identity document, or application for certification of special qualifications. This physical
examination must be carried out not more than 12 months prior to th e date of m aking application for an officer
certificate, certification of special qualifications or a seafarer's book. Such proof of examination must establish that
the applicant is in satisfactory physical condition for the specific duty assignment undertaken and is g enerally in
possession of all body faculties necessary in fulfilling the requirements of the seafaring profession. In addition, the
following minimum requirements shall apply:
(a) All applicants must have heari ng unimpaired for normal sounds and be capable of hearing a whi spered
voice in the better ear at 15 feet and in the poorer ear at 5 feet.
(b) Deck officer applicants must have (either with or without glasses) at least 20/20 vision in one eye and at
least 20/40 in the other. If the applicant wears glasses, he m ust have vision without glasses of at least
20/160 in both eyes. Deck officer applicants must also have normal color perception and be capable of
distinguishing the colors red, green, blue and yellow.
(c) Engineer and radio officer applicants must have (either with or without glasses) at least 20/30 vision in one
eye and at least 20/50 in the other. If the applicant wears glasses, he must have vision without glasses of at
least 20/200 in both eyes. Engineer and radio officer applicants must also be able to perceive the colors red,
yellow and green.
(d) An applicant's blood pressure must fall within an average range, taking age into consideration.
(e) Applicants afflicted with any o f the following diseases or co nditions shall be disqualified: epilepsy,
insanity, senility, alcoholism, tuberculosis, acute venereal disease or neurosyphilis, AIDS and/or the use of
narcotics.
(f) Deck/Navigational officer applicants and Radio officer applicants must have speech which is unimpaired
for normal voice communication.
(g) Applicants for able seaman, bosun, GP-1, ordinary seaman and junior ordinary seaman must meet the
physical requirements for a deck/navigational officer's certificate.
(h) Applicants for fireman/watertender, oiler/motorman, pumpman, electrician ,wiper, tankerman and survival
craft/rescue boat crewman must meet the physical requirements for an engineer officer's certificate.
DETAILS OF MEDICAL EXAMINATION
(To be completed by examining physician)
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
2
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- Annex 2 RLM 105M Rev.11 2012

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Completed 13 February 2021

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