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CG-719K (04/17) Previous Editions Obsolete Page 1 of 10
DEPARTMENT OF HOMELAND SECURITY OMB No. 1625-0040
U.S. Coast Guard Exp. Date: 03/31/2021
APPLICATION FOR MEDICAL CERTIFICATE (FORM CG-719K)
------ Instructions ------
Who must submit this form?
1. Applicants seeking a Medical Certificate are required to complete this form and submit all 10 pages, including instructions, to the U.S. Coast Guard. Guidance
for completion of this form can be found at https://www.uscg.mil/hq/cg5/nvic/pdf/2008/NVIC_04-08.pdf.
2. Mariners applying for or holding a merchant mariner credential with only an entry-level endorsement who serve on a vessel not subject to the International
Convention on Standards of Training, Certification and Watchkeeping (STCW) but who request a medical certificate that satisfies the Maritime Labor
Convention (MLC), AND want to be qualified for lookout duties should submit this form. Sections III (Medical Conditions), IV (Medications) and V
(Physical Examination) of the CG 719K DO NOT have to be completed. The medical certificate will be restricted to entry-level only.
3. The Coast Guard will not accept an application for a medical certificate without a reference number or a Merchant Mariner Credential (MMC).
Section I: Applicant Information - To be completed by the Applicant and reviewed by the Medical Practitioner (MP)
•
Legal Name - Enter complete legal name.
• Date of Birth - If applicant is under 18 years of age, attach a notarized statement, signed by a parent or guardian, authorizing the Coast Guard to issue a
Medical Certificate.
• Mariner Reference Number or Social Security Number - If you have held a Coast Guard credential in the past, enter your reference number.
• Gender - Enter your gender.
• Home Address - Principle place of residence. PO Box is not acceptable.
• Delivery/Mailing Address - The address to which you want all correspondence and issued certificates sent. If blank, correspondence and certificates will be
sent to the Home Address.
• Primary Phone Number - Provide a primary phone number.
• Alternate Phone Number - Provide an alternate phone number (optional).
• E-mail Address - (Optional) If provided, the National Maritime Center (NMC) may attempt to contact you via e-mail. You will receive automated updates
regarding the status of your application.
• Other - Please provide additional means of communicating with you (satellite phone, work phone, etc.) (optional).
•
Endorsement held or sought - Applicants should select all options that apply. If nothing is selected, the Coast Guard will not accept the application.
Section III: Medical Conditions - To be completed by the Applicant and the Medical Practitioner
III(a) Applicants must report their relevant medical conditions to the best of their knowledge. Applicants should check YES if: 1) they have had a previous
diagnosis, or treatment for the condition by a health care provider; 2) they are currently under treatment or observation for the condition; or 3) the condition
is present, regardless of treatment status.
III(b) The Medical Practitioner must review and discuss all conditions reported by the applicant in Section III(a). The Medical Practitioner's discussion should
include, at a minimum, the name of the condition, approximate date of diagnosis, treatment, current status of the condition, limitations of the condition, and
any additional information as appropriate. Recommended supporting documentation and testing for conditions that are subject to further review are
contained in the Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials which can be found at https://www.uscg.mil/hq/cg5/nvic/
pdf/2008/NVIC_04-08.pdf. Medical practitioners should be familiar with the guidelines contained within this document. If the Medical Practitioner
discovers a condition not reported by the applicant, they must check YES in the appropriate block in III(a) and provide information on the condition, as
requested, in Section III(b). For conditions that were Previously Reported, the Medical Practitioner need only discuss the interval history and current
status of the condition. Additional sheets may be added by the applicant and/or the medical practitioner if needed to complete this section of the form.
Include applicant's name and DOB on each additional sheet. The Medical Practitioner should initial and date at the bottom of each page of the
application, where indicated.
Refer to instructions provided in this section. The Medical Practitioner should initial and date at the bottom of each page of the application, where indicated.
Section II: Food Handler Certification - To be completed by the Medical Practitioner
DATE:MEDICAL PRACTITIONER INITIALS:
Who may conduct this exam?
1. All exams, tests and demonstrations must be performed, witnessed or reviewed by a physician, physician assistant, or nurse practitioner licensed by a state
in the U.S., a U.S. possession, or a U.S. territory.
2. Medical examinations for U.S. Registered Pilots must be conducted by a licensed medical doctor.
Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)
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CG-719K (04/17) Previous Editions Obsolete Page 2 of 10
Section IX: Summary - To be completed by the Medical Practitioner
a. Applicant Proof of Identity Provided - Applicants shall present acceptable proof of identity to the Medical Practitioner conducting examinations. Proof of
identity shall consist of one current form of valid government-issued photo identification. Examples of acceptable proof of identity include unexpired official
identification issued by a Federal, State, or local government or by a territory or possession of the United States, such as a passport, U.S. driver's license,
U.S. military ID card, Merchant Mariner Credential, or Transportation Worker Identification Credential.
b. Certification recommendation - The Medical Practitioner must ensure a complete history and physical are conducted. The practitioner should address
the listed questions and make a certification recommendation. The Coast Guard retains final authority for the issuance of the medical certificate.
c. Assessment - The Medical Practitioner should provide answer to statement 1 or 2, as appropriate for the credential sought. Option 2 is for mariner
applicants who are only seeking an MLC-compliant, entry-level medical certificate.
d. Discussion - The Medical Practitioner should discuss any conditions or issues of concern.
e. Medical Practitioner (Attestation and Information) - Attests that the general medical examination, vision and hearing tests, and demonstration of physical
ability, as appropriate, have been performed to the satisfaction of the Medical Practitioner. The Medical Practitioner must sign and date the attestation
where indicated. This signature attests, subject to criminal prosecution under 18 USC § 1001, that all information reported by the Medical Practitioner is
true and correct to the best of their knowledge and that the Medical Practitioner has not knowingly omitted or falsified any material information relevant to
this form.
Section X: Applicant Certification - To be completed by the Applicant
Applicant certifies that the information provided is true and correct.
Section XI: Applicant Consent (optional) - To be completed by the Applicant
Third Party Authorization - If you want the NMC to be able to discuss, release, or receive information/documents regarding your medical certificate application
with a third party (spouse, employer, school, union, etc.) you must provide specific guidance to the NMC regarding what issues we may discuss and with whom.
You may allow release of all information to certain individuals or entities. If you limit the release of certain information you must be specific by making a selection
on the application or by attaching additional documentation. For each selection made, ensure the Name of the Organization or Third Party, Organization Point of
Contact (if applicable), Address and Phone Number is completed. If you wish to provide multiple Third Party Authorizations, attach additional pages as needed. A
sample may be found on the NMC website: https://www.uscg.mil/nmc/credentials/forms/3rd_party_authorization_med_cert.pdf. Please sign and date for
each type of consent that you wish to authorize.
a. Consent for Medical Practitioner to Release Information to the Coast Guard
b. Consent for Coast Guard to Release Information to a Third Party
c. Consent for Third Party to Act on your Behalf
Section VI: (Vision) and VII: (Hearing) - To be completed by the Medical Practitioner or other staff to the satisfaction of
the Medical Practitioner
The Medical Practitioner is not required to perform or witness the vision and hearing examinations. These may be performed by qualified office staff or
referred to other qualified practitioners such as audiologists or optometrists; however, the results must be reviewed by the Medical Practitioner.
The Medical Practitioner should initial and date at the bottom of each page of the application, where indicated.
Additional guidance can be found at: https://www.uscg.mil/hq/cg5/nvic/pdf/2008/NVIC_04-08.pdf.
The Medical Practitioner must document the results of the physical examination in this section. The Medical Practitioner should initial and date at the bottom
of each page of the application, where indicated.
Section V: Physical Examination - Items 1-17; To be performed and completed by the Medical Practitioner
Refer to the table and instructions provided in this section. The Medical Practitioner should initial and date at the bottom of each page of the application, where
indicated.
Section VIII: Demonstration of Physical Ability - To be completed by the Medical Practitioner
DATE:MEDICAL PRACTITIONER INITIALS:
Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)
Applicants - Refer to instructions provided in this section.
Medical Practitioner - Verification of medications includes questioning the applicant about any medications or other substances reported, reviewing relevant
medical conditions to determine if the applicant has omitted any medications or other substances, and affirmatively reporting any omitted current medications or
other substances where required. The Medical Practitioner should initial and date at the bottom of each page of the application, where indicated.
Section IV: Medications - To be completed by the Applicant and reviewed by the Medical Practitioner
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CG-719K (04/17) Previous Editions Obsolete Page 3 of 10
Section I: Applicant Information - To be completed by the Applicant and reviewed by the Medical Practitioner
Last Name
First Name
Middle Name Suffix (Jr., Sr., III)
Mariner Reference Number or Social Security Number Gender: Date of Birth (MM/DD/YYYY)
Please indicate best method(s) of contact by checking the appropriate box(es).
Zip CodeStateCity
Street Address
Home Address (PO Box NOT acceptable)
Delivery/Mailing Address, if different (PO Box acceptable)
Zip CodeStateCity
Primary Phone Number
Alternate Phone Number
E-mail Address
Other
Street Address
Endorsement Held or Sought (Check all that apply or the Coast Guard will not accept the application):
Deck STCWEngine Food Handler
U.S. Registered Pilot (Great Lakes Pilotage)
1. Food Handlers must obtain a statement from the Medical Practitioner that attests that they are free of communicable diseases that pose a direct threat to
the health or safety of other individuals in the workplace. For applicants who have requested Food Handler Certification (Food Handler box is checked in
Section I, above), the Medical Practitioner may provide the attestation by answering Yes or No to the question in bold below.
2. Communicable disease is defined in 46 CFR 10.107 as any disease capable of being transmitted from one person to another directly, by contact with
excreta or other discharges from the body; or indirectly, via substances or inanimate objects contaminated with excreta or other discharges from an infected
person.
3. The Medical Practitioner need not perform any additional testing unless it is deemed clinically necessary. Applicants and currently employed food workers
should report information about their health as it relates to diseases that are transmissible through food. Circumstances that the Medical Practitioner should
consider when certifying an applicant include, but are not limited to, the following:
a. Whether the applicant reports they have been diagnosed with, or exposed to an illness due to organisms including, but not limited to, Salmonella Typhi,
Shigella Spp., Shiga-toxin-producing Escherichia coli, or Hepatitis A virus within the past month.
b. Whether the applicant reports they have at least one symptom caused by illness, infection, or other source that is associated with an acute
gastrointestinal illness such as diarrhea, fever, vomiting, jaundice, or sore throat with fever.
c. Whether the applicant reports they have a lesion containing pus, such as a boil or infected wound, which is open or draining and is on hands or wrists or
on exposed portions of the arms.
Section II: Food Handler Certification - To be completed by the Medical Practitioner
Yes
No
N/A
Is the applicant free from communicable disease?
DEPARTMENT OF HOMELAND SECURITY OMB No. 1625-0040
U.S. Coast Guard Exp. Date: 03/31/2021
APPLICATION FOR MEDICAL CERTIFCATE (FORM CG-719K)
DATE:MEDICAL PRACTITIONER INITIALS:
First-Class Pilot or those Serving as Pilot (Federal Pilotage/46 CFR 15.812)
Entry-level with lookout duties
Other (Please explain):
FemaleMale
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CG-719K (04/17) Previous Editions Obsolete Page 4 of 10
Section III(a): Medical Conditions - To be completed by the Applicant and reviewed by the Medical Practitioner
To the best of your knowledge, have you ever had, required treatment for, or do you presently have any of the following conditions? If no,
please mark the NO box below. If yes, please mark the YES box below, and if previously reported (PR), mark the PR box below.
I have a medical waiver (MW): If YES, provide a copy to the Medical Practitioner, and mark the MW box below.
Yes
No
DATE:
Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)
MEDICAL PRACTITIONER INITIALS:
ITEM YES NO PR MW CONDITIONS
1. 1. Blurry vision, poor night vision, eye disease or injury, eye surgery, abnormal color vision, cataracts or glaucoma
2. 2. Hearing loss, hearing aid, ear surgery, facial deformities, open tracheostomy or frequent severe nose bleeds
3. 3. High or low blood pressure
4.
4. Heart or vascular disease of any kind, to include angina, chest pain, irregular heart beat, heart valve problem/
replacement, heart attack/myocardial infarction, or congestive heart failure
5. 5. Heart surgery and/or implanted devices (for example, angioplasty, stent, pacemaker, or defibrillator)
6. 6. Lung disease of any type (for example, asthma, emphysema, or chronic obstructive pulmonary disease (COPD))
7. 7. Any blood disorder (for example, anemia, hemophilia, blood clots, or polycythemia)
8. 8. Diabetes, glucose intolerance, or sugar in urine
9. 9. Thyroid problem requiring treatment or hospitalization
10.
10. Stomach, liver or intestinal disorder requiring ongoing medical care/medication, or causing significant bleeding
or debilitating pain; history of hepatitis or jaundice
11. 11. Kidney problems/stones or blood in urine
12. 12. Any other urinary or bladder problems not listed above requiring treatment or hospitalization
13. 13. Skin disorders requiring medical treatment, such as cancer, tumors, scleroderma or lupus
14. 14. Severe allergies or allergic reactions to any substance, medication, food, or insect stings
15. 15. Communicable disease or chronic infectious diseases such as tuberculosis, HIV/AIDS, or hepatitis
16.
16. Any sleep problems (for example, obstructive sleep apnea, restless leg syndrome, narcolepsy, shift work
sleep disorder, or insomnia)
17. 17. Epilepsy, fits, or seizures
18. 18. History of serious head injury, loss of consciousness or memory loss
19. 19. Frequent or severe headaches
20. 20. Dizziness/fainting spells/balance problems
21. 21. Frequent motion sickness requiring medication
22. 22. Stroke or Transient Ischemic Attack (TIA), brain tumor or other brain disorder
23. 23. Any neurologic disorder or nerve problems including numbness and/or paralysis, not listed above
24. 24. Attention deficit disorder with or without hyperactivity
25. 25. Anxiety, depression, bipolar disorder, adjustment disorder, PTSD, or schizophrenia
26. 26. Suicide attempt or thought(s) of suicide (Suicidal Ideation)
27.
27. Evaluation, treatment, or hospitalization for alcohol or substance use, abuse, addiction, or dependence
(including illegal drugs, prescription medications, or other substances)
28. 28. Any other psychiatric disorder, mental health evaluation/treatment/hospitalization
29. 29. Back, neck or joint problems that impair movement or cause debilitating pain
30. 30. Amputation, prosthesis, or use of ambulatory devices (for example, cane, walker, or braces)
31. 31. Injuries, fractures or recurrent dislocations causing impairment or limitation of motion of any joint
32. 32. Have you ever been signed off a vessel as sick or repatriated for medical reasons within the last six years?
33. 33. Any diseases, surgeries, cancers, illnesses, or disabilities not listed on this form?
34. 34. Any hospital admissions within the last six years not listed elsewhere in this Section?
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CG-719K (04/17) Previous Editions Obsolete Page 5 of 10
Section III(b): Medical Conditions - To be completed by the Medical Practitioner
Instructions: For each item marked YES in Section III(a), the Medical Practitioner must provide the information requested IN THE BLOCKS
below. For each condition marked Previously Reported (PR), the provider need only discuss the interval history and current status of the
condition.
For conditions with a Medical Waiver (MW) review the applicant's waiver letter and attach all waiver reporting requirements.
Please attach appropriate evaluation data for conditions that are subject to further review. Information on conditions that are subject to
further review and the recommended evaluation data can be found in the Medical and Physical Evaluation Guidelines for Merchant Mariner
Credentials, located at https://www.uscg.mil/hq/cg5/nvic/pdf/2008/NVIC_04-08.pdf.
Indicate whether additional information has been attached by marking the ATTACHED box. Additional sheets may be added, if needed to
complete this section (include applicant name and date of birth on each additional sheet).
LimitationsStatus
TreatmentCondition
DATE:MEDICAL PRACTITIONER INITIALS:
Attached
Date of onset or diagnosis (mm/dd/yyyy)
Item #
LimitationsStatus
TreatmentCondition
Attached
Date of onset or diagnosis (mm/dd/yyyy)
Item #
LimitationsStatus
TreatmentCondition
Attached
Date of onset or diagnosis (mm/dd/yyyy)Item #
LimitationsStatus
TreatmentCondition
Attached
Date of onset or diagnosis (mm/dd/yyyy)Item #
LimitationsStatus
TreatmentCondition
Attached
Date of onset or diagnosis (mm/dd/yyyy)
Item #
Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)
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CG-719K (04/17) Previous Editions Obsolete Page 6 of 10
Please make comments in the space provided on any item indicated as an "abnormal" system/organ.
DATE:
Section IV: Medications - To be completed by the Applicant and reviewed by the Medical Practitioner
MEDICATION DOSE FREQUENCY CONDITION MEDICAL PRACTITIONER COMMENTS (Duration of Use/Side Effects)
Applicants Must Report
1. All medications (Prescription or Nonprescription), dietary supplements, and
vitamins; that were filled, or refilled, and/or taken within 30 days prior to the date
the applicant signs the CG-719K; and
2. All medications (Prescription or Nonprescription), dietary supplements, and
vitamins that were used for a period of 30 or more days within the last 90 days
prior to the date the applicant signs the CG-719K.
Section V: Physical Examination - Items 1-17 must be performed and completed by the Medical Practitioner.
Height
(inches only):
Pulse
Resting:
Weight
(lbs):
Blood
Pressure:
Body Mass Index (BMI):
(For BMI > 40 refer to Section VIII)
Additional Medical Comments (Please Print)
Medical Practitioner
1. Medical Practitioner must verify applicants medications and information
listed in the table below.
2. Medical Practitioner comments should include the approximate length
of time the applicant has taken the medication and address the
presence or absence of any side effects.
Additional sheets may be attached by the Applicant and/or Medical Practitioner if needed to complete this section.
(Include applicant name and date of birth on each additional sheet and check the box indicated on the right)
ATTACHED
MEDICAL PRACTITIONER INITIALS:
If YES, provide the information requested in the blocks below.
Yes
No
Do you currently use any medication (prescription or nonprescription)?
REPORT OF MEDICAL EXAMINATION
Additional guidance on medications, including those that may be considered disqualifying, can be found at
https://www.uscg.mil/hq/cg5/nvic/pdf/2008/NVIC_04-08.pdf.
Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)
1. Head, Face, Neck, Scalp
6. Heart
5. Lungs and Chest
4. Ears/Drums
3. Mouth and Throat
2. Eyes/Pupils/EOM
Item Normal
7. Upper/Lower Extremities
12. Extremities/Digit
11. General/Systemic
10. Abdomen
9. Vascular System
8. Spine/Musculoskeletal
Item Normal Abnormal
13. Skin
16. Hernia
15. Mental Status
14. Neurologic
Item Normal Abnormal
YesNo
Abnormal
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CG-719K (04/17) Previous Editions Obsolete Page 7 of 10
Section VI: Vision - Must be performed by the Medical Practitioner, their medical staff or other qualified practitioner. Results
must be reviewed by the Medical Practitioner. Additional guidance can be found at https://www.uscg.mil/hq/cg5/nvic/
pdf/2008/NVIC_04-08.pdf.
a. Visual Acuity
b. Color Vision: The Medical Practitioner should assess the applicant's color vision sense using one of the following testing methodologies.
The Medical Practitioner must indicate which test was utilized, and the number of errors obtained. In order to meet the
standard, the applicant must demonstrate satisfactory color sense without the use of color enhancing lenses.
Section VII: Hearing - Must be performed by the Medical Practitioner, their medical staff or other qualified practitioner.
Results must be reviewed by the Medical Practitioner.
An applicant with normal hearing by forced whispered voice > 5 feet with or without hearing aids does not need to complete either the audiometer test or the
functional speech discrimination test.
(a) If hearing is abnormal, then perform either a functional speech discrimination test at 65dB or an audiogram documenting thresholds and averages as
indicated below. Both aided and unaided values should be recorded for applicants requiring hearing aids.
(b) All applicants with an unaided threshold > 30dB in the better ear should have functional speech discrimination testing performed at 65dB.
(c) Refer to Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials which can be found at https://www.uscg.mil/hq/cg5/nvic/pdf/2008/
NVIC_04-08.pdf for further guidance. Report any additional information or comments in Section IX.
Distance Vision, Uncorrected:
Right: 20/
Left: 20/
If correction required, Distance Vision Correctable To:
Right: 20/
Left: 20/
Field of Vision
AOC (1965) - (6 or fewer errors on plates 1-15)
AOC-HRR (2nd Edition) - (No errors in test plates 7-11)
HRR PIP (4th Edition) - (No errors in test plates 5-10)
Richmond (2nd and 4th Edition) - (6 or fewer errors)
Titmus Vision Tester/OPTEC 2000 - (No errors on 6 plates)
OPTEC 900 (colored lights) Test per instruction booklet
Farnsworth D-15 Hue Test (Engineer/radio officer/tankerman/MODU only)
Ishihara pseudoisochromatic plates test, 14 plate (5 or less errors)
Ishihara pseudoisochromatic plates test, 24 plate (6 or less errors)
Ishihara pseudoisochromatic plates test, 38 plate (8 or less errors)
Farnsworth Lantern (colored lights) Test per instruction booklet
Dvorine (2nd Edition) pseudoisochromatic 15 plate test (6 or less errors)
Passed Failed
Color Vision Testing Results:
Number of Errors:
Normal Hearing Abnormal Hearing Hearing Aid Required
500Hz 1,000Hz 2,000Hz 3,000Hz Average
Right Ear (Unaided)
Left Ear (Unaided)
Right Ear (Aided)
Left Ear (Aided)
Audiometer
Threshold Value
Functional Speech
Discrimination Test @ 65dB, if required by
instruction (b) above
Right Ear (Unaided):
Left Ear (Unaided):
Right Ear (Aided):
Left Ear (Aided):
Normal (the applicant's horizontal field of vision is
greater than or equal to 100 degrees).
Abnormal
%
%
%
%
DATE:
Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)
MEDICAL PRACTITIONER INITIALS:
Alternative Testing (attach evaluation/test results):
Formal ophthalmology/optometry color vision evaluation
Other alternative test acceptable to the Coast Guard
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CG-719K (04/17) Previous Editions Obsolete Page 8 of 10
1. The Medical Practitioner should indicate whether the applicant can meet the guidelines listed in the table above. If the Medical Practitioner doubts the applicant's
ability to meet the guidelines contained within this table, and for all applicants with a Body Mass Index (BMI) of 40 or higher, the practitioner should require that the
applicant demonstrate the ability to meet the guidelines contained within this table. This does not mean, for example, that the applicant must actually don an exposure
suit, pull an unchanged 1.5 inch diameter 50' fire hose with nozzle to full extension, or lift a charged 1.5 inch diameter fire hose to firefighting position. Rather, the
Medical Practitioner may utilize alternative measures to satisfy themselves that the applicant possesses the ability to meet the guidelines in the third column. A
description of the methods utilized by the Medical Practitioner should be reported in the Comments section provided below.
2. All practical demonstrations should be performed by the applicant without assistance. Any prosthesis normally worn by the applicant, and any other aid devices, may
be used by the applicant in all practical demonstrations except when the use of such items would prevent the proper wearing of mandated personal protection
equipment (PPE).
3. If the Medical Practitioner is unable to conduct the practical demonstration, the applicant should be referred to a competent evaluator of physical ability. The Coast
Guard recognizes that not all medical practitioners will have the equipment necessary to test all of the tasks as listed. Equivalent alternate testing methodologies may
be used. For further information, check the Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials which can be found at https://www.uscg.
mil/hq/cg5/nvic/pdf/2008/NVIC_04-08.pdf.
4. If the applicant is unable to perform all of the functions listed in the table above, the Medical Practitioner should provide information on the degree or the severity of
the applicant's inability to meet the standards. The results of any practical demonstration or attendant physical evaluation should be recorded in the Comments section
provided below.
Applicant has the physical strength, agility, and flexibility to
perform all of the items listed in the physical ability table.
Applicant does NOT have the physical strength, agility, and flexibility
to perform all of the items listed in the physical ability table.
Physical Ability
Results:
COMMENTS:
(Please Print)
LISTS OF TASKS CONSIDERED NECESSARY FOR PERFORMING ORDINARY AND EMERGENCY RESPONSE SHIPBOARD FUNCTIONS
Shipboard Tasks, Function, Event, or
Condition
Related Physical Ability The Examiner Should Be Satisfied That The Applicant:
Routine movement on slippery, uneven,
and unstable surfaces
Maintain balance (equilibrium)
Has no disturbance in sense of balance
Routine access between levels Climb up and down vertical ladders and stairways
Is able, without assistance, to climb up and down vertical ladders
and stairways
Routine movement between spaces and
compartments
Step over high doorsills and coamings, and move
through restricted accesses
Is able, without assistance, to step over a doorsill or coaming of 24
inches (600 millimeters) in height. Able to move through a
restricted opening of 24 x 24 inches
Open and close watertight doors, hand
cranking systems, open/close valve
Manipulate mechanical devices using manual and digital
dexterity, and strength
Is able, without assistance, to open and close watertight doors that
may weigh up to 55 pounds (25 kilograms); should be able to
move hands/arms to open and close valve wheels in vertical and
horizontal directions; rotate wrists to turn handles; able to reach
above shoulder height
Handle ship's stores Lift, pull, push, carry a load
Is able, without assistance, to lift at least a 40 pound (18.1
kilograms) load off the ground, and to carry, push, or pull the same
load
General vessel maintenance
Crouch (lowering height by bending knees); kneel
(placing knees on ground); stoop (lowering height by
bending at the waist); use hand tools such as span-ners,
valve wrenches, hammers, screwdrivers, pliers
Is able, without assistance, to grasp, lift, and manipulate various
common shipboard tools
Emergency response procedures
including escape from smoke-filled
spaces
Crawl (ability to move body using hands and knees); feel
(ability to handle or touch to examine or determine
differences in texture and temperature)
Is able, without assistance, to crouch, kneel, and crawl, and to
distinguish differences in texture and temperature by feel
Stand a routine watch Stand a routine watch
Is able, without assistance, to intermittently stand on feet for up to
four hours with minimal rest periods
React to visual alarms and instructions,
emergency response procedures
Distinguish an object or shape at a certain distance Fulfills the eyesight standards for the merchant mariner credential
React to audible alarms and
instructions, emergency response
procedures
Hear a specified decibel (dB) sound at a specified
frequency
Fulfills the hearing standards for the merchant mariner credential
Make verbal reports or call attention to
suspicious or emergency conditions
Describe immediate surroundings and activities, and
pronounce words clearly
Is capable of normal conversation
Participate in fire fighting activities
Be able to carry and handle fire hoses and fire
extinguishers
Is able, without assistance, to pull an uncharged 1.5 inch diameter,
50' fire hose with nozzle to full extension, and to lift a charged 1.5
inch diameter fire hose to fire fighting position
Abandon ship Use survival equipment
Has the agility, strength, and range of motion to put on a personal
flotation device and exposure suit without assistance from another
individual
Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)
Section VIII: Demonstration of Physical Ability - To be completed by the Medical Practitioner
DATE:MEDICAL PRACTITIONER INITIALS:
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Section IX: Summary - To be completed by the Medical Practitioner
NoYes
a. Applicant proof of identity provided:
d. Discussion: Please discuss any conditions subject to further review identified in Section III(b) or any other concerns. Please print or type.
e. Medical Practitioner: My signature attests, subject to criminal prosecution under 18 USC § 1001, that all information reported by me is true and
correct to the best of my knowledge and that I have not knowingly omitted or falsified any material information relevant to this form. My signature also attests
that I have fully evaluated all examination tests and results submitted in support of this application.
Zip CodeStateCity
Office Street Address
M.I.First NameLast Name
Date (MM/DD/YYYY)Signature
MD PA NP
License Number State
(Place office address stamp here)
Section X: Application Certification - To be completed by the Applicant
My signature below attests, subject to prosecution under 18 USC § 1001, that all information provided by me on this form is complete and true to the best of
my knowledge, and I agree that it is to be considered part of the basis for issuance of any medical certificate to me. I have not knowingly omitted any
material information relevant to this form. I have also read and understand the Privacy Notice that accompanies this form.
Signature of Applicant Date (MM/DD/YYYY)
Phone Number
c. Assessment: 1. Preliminary screening indicates that the applicant is not at high risk of having a condition(s) that poses a significant risk of sudden incapacita-
tion or debilitating complication, to include, uncontrolled obstructive sleep apnea, diabetes mellitus or coronary
artery disease:
NoYes
Needs Further Review
Recommended Not Recommended Needs Further Review
b. Certification recommendation:
Authority: 14 U.S.C. 632; 46 U.S.C. 2103, 7101, 7302, 7502, 46 C.F.R. 10.301
Purpose: The information is collected by the Coast Guard to determine whether an applicant meets the regulatory standards for issuance of a U.S. Merchant
Mariner Credential (MMC). The Coast Guard evaluates an applicant's qualifications to determine compliance with the national and international requirements for
issuance of the MMC, any endorsement within the MMC, and medical certificate.
Routine Uses: The information is used by authorized Coast Guard personnel who have a need for the record to determine whether an applicant is a safe and
suitable person and qualifies for the MMC, any endorsement within the MMC, and medical certificate. In addition, the Coast Guard uses this information to
maintain and update records of merchant mariner documentation transactions. The information will not be shared outside of DHS except in accordance with the
provisions of DHS/USCG-030 Merchant Seamen's Records System of Records, 74 FR 30308 (June 25, 2009).
Disclosure: Furnishing this information (including your SSN) is voluntary; however, failure to furnish the requested information may result in the non-issuance
of the MMC, any endorsement within the MMC, and medical certificate.
PRIVACY NOTICE
An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number.
The United States Coast Guard estimates that the average burden for this form is 18 minutes. You may submit any comments concerning the accuracy of this
burden or any suggestions for reducing the burden to the Chief, Office of Merchant Mariner Credentialing, 2703 Martin Luther King, Jr. Ave,
S.E., STOP 7509,
Washington, D.C., 20593-7509.
Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)
DO
OR,
2. (Entry-level, only) - To the best of my knowledge, mariner applicant is free from any medical condition likely to be aggravated by service at sea or to render the
seafarer unfit for such service or to endanger the health of other persons on board.
Yes No
Needs Further Review
Reset
CG-719K (04/17) Previous Editions Obsolete Page 10 of 10
a. CONSENT FOR MEDICAL PRACTITIONER TO RELEASE INFORMATION TO THE COAST GUARD:
My signature below authorizes the Medical Practitioner, who has signed the certification on page 9 of this form, to release to, or discuss with authorized
Coast Guard personnel, any pertinent information in his/her possession regarding any physical or medical condition that may require review by the Coast
Guard prior to determining whether the Coast Guard should issue a merchant mariner medical certificate.
I understand that this authorization is voluntary. I also understand that failure to provide authorization could affect the Coast Guard's ability to make a timely
determination as to whether the Coast Guard should issue me a merchant mariner medical certificate. This authorization will remain in effect until the Coast
Guard determines whether to issue me the requested merchant mariner medical certificate for maritime service, but no longer than one year.
I have read and understand the following statement about my rights:
u I may revoke this authorization at any time prior to its expiration date by notifying the verifying medical practitioner in writing, but the revocation will
not have any effect on any actions taken before they received the notification.
u Upon request, I may see or copy the information described in this release.
u I am not required to sign this release to receive my medical evaluation.
Signature of Applicant Date (MM/DD/YYYY)
b. CONSENT FOR COAST GUARD TO RELEASE INFORMATION TO A THIRD PARTY:
My signature authorizes the Coast Guard to share my medical information with the third party indicated below. I understand that I may revoke this
authorization at any time prior to its expiration date by notifying the Coast Guard in writing.
Please provide the Name of the Organization or Third Party, Address, and Phone Number. Additional Third Party Authorization information may be
attached separately.
Signature of Applicant Date (MM/DD/YYYY)
Name of Organization or Third Party
Organization Point of Contact (if applicable) Phone Number
Street Address
Signature of Applicant Date (MM/DD/YYYY)
StateCity Zip Code
c. CONSENT FOR THIRD PARTY TO ACT ON MY BEHALF:
My signature authorizes the following third party to act on my behalf in all matters pertaining to the processing of my current application for a medical
certificate. This means that the Coast Guard will share my medical information and correspond with the third party, and it means that the third party can
request agency action on my behalf, and receive my medical certificate.
I understand that I may revoke this authorization at any time prior to its expiration date by notifying the Coast Guard in writing.
Please provide the Name of the Organization or Third Party, Address, and Phone Number. Additional Third Party Authorization information may be attached
separately.
Name of Organization or Third Party
Organization Point of Contact (if applicable) Phone Number
Street Address
StateCity Zip Code
Section XI: (Optional) Applicant Consent - To be completed by the Applicant
Declined
Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)
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Completed 20 May 2020

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