International Seafarer Medical Certificate Declaration

Seafarer Details

Full Name
Date of Birth
Nationality
Seafarer ID/Passport No.
Rank/Position
Vessel Name
Company/Shipowner

Medical Examination

Date of Examination
Place of Examination
Medical Certificate No.
Valid Until

Medical Declaration

I, the undersigned, hereby certify that I have examined the above-named seafarer in accordance with the applicable medical standards and guidelines for seafarers. Based on the examination, the seafarer is:

Fit for Duty at Sea
Fit for Duty with Restrictions
Unfit for Duty

Comments/Restrictions:

Seafarer's Signature

Date

Authorized Medical Examiner's Signature & Stamp

Date