MSF 4112 / REV0305 SEAFARER MEDICAL REPORT FORM (ML5) AND ML5 CERTIFICATE WHO MAY USE THIS FORM
This form is for use in connection with an application for:
a) a Boatmaster's Licence for use on a non-seagoing local passenger boat ; b) an RYA Certificate or Boatmaster's Licence for operation under the MCA Small Commercial Vessel Code, or Large Yacht Code in Area Categories 2, 3, 4, 5 or 6 (i.e. up to 60 miles from shore); c) crew members on seagoing local passenger boats; d) those working on vessels operating under the MCA Small Commercial Vessels or Large Yacht Codes of Practice in Area Categories 2, 3, 4, 5 or 6 (i.e. up to 60 miles from shore) . Note: Applicants for a Boatmaster's Licence (BML) to work as skipper on a passenger boat (more than 12 passengers) at sea (beyond categorised waters), and those working on vessels operating under the Small Commercial Vessel Code in Area Categories 1 and 0 (i.e.more than 60 miles from shore), require a seafarer medical certificate (ENG 1 - MSF 4104) which may only be issued by an MCA approved doctor, or a medical certificate issued by a country recognised as equivalent. An ENG 1 medical certificate is always acceptable as an alternative to the ML5 certificate. Details of the procedure for obtaining an ENG 1 and list of doctors and equivalent certificates are given in Merchant Shipping Notices MSNs 1765(M),1787(M), and 1788 (M) available from any MCA Marine Office, or from the MCA's webpage www.mcga.gov.uk under 'Guidance & Regulations'.
Further details of medical requirements for non-seagoing Boatmasters, and those working on local passenger ships, vesselsoperating under MCA Codes of Practice and non-seagoing local passenger vessels, are given in Marine Guidance Note 264(M)
TO THE APPLICANT WHAT TO DO
First read the Notes about Fitness below. Then take the form to any Medical Practitioner registered with the UK General Medical Council (preferably your GP), for completion of Part B of the form and the certificate at Part C. He/she may charge you a fee for this report. If you have any doubts about your fitness, discuss them with the Doctor before you ask him/her to complete this form.
Complete Part A of the form (but do not sign the declaration until you are with the Doctor). NOTES ABOUT FITNESS You are unlikely to be issued with an unrestricted Boatmaster's Licence or RYA Certificate if,
you are liable to epileptic seizures or sudden disturbances of the state of consciousness you have had a coronary thrombosis or have undergone heart surgery you suffer problems with heart rhythm, or have a disease of the heart or arteries your blood pressure is not well controlled with drugs you need injections of insulin for diabetes you have had a stroke, or unexplained loss of consciousness you have had severe head injury with continuing loss of consciousness you suffer from Parkinson's Disease or Multiple Sclerosis you are being treated for mental or nervous problems you have had alcohol or drug addiction problems within the last 2 years you have profound deafness and cannot communicate on the radio/telephone you suffer from double or tunnel vision you have any other condition which would/could cause problems regarding your fitness to navigate a vessel.
You must tell the issuing authority (MCA Marine Office or RYA) if, during the validity of your ML5 certificate, youdevelop any of the above conditions or a disability which affects your fitness to work. This includes mental as well asphysical conditions. Your BML/RYA Certificate will not be valid during your illness and you will need to obtain a newML5 report/certificate once you have recovered.
Those not applying for a BML/RYA Certificate do not need to have their ML5 certificates endorsed by the RYA orMCA Marine Office, but should retain them for inspection as necessary, noting the 5 year validity. Anyone in thiscategory who has a tick on the ML5 form indicating a medical condition affecting their fitness may apply to the MCAfor review by a Medical Assessor, via the RYA or any MCA Marine Office. MSF 4112 / REV0305 PURPOSE OF THE ML5 REPORT AND CERTIFICATE
The purpose of the ML5 form is to obtain a factual report of your state of health and medical history and to indicate your fitness for working on board a boat. The form is designed so that, if Part B of the report shows ticks in Box 2 only, without any qualifying remarks by the doctor, he/she will also complete Part C which is an ML5 certificate indicating you are medically fit to hold a BML or RYA Certificate or to work on vessels listed on the front of this form. You should then submit the form to an MCA Marine Office or the RYA in support of your application for a BML or RYA Certificate. Your ML5 certificate will be endorsed and returned to you to retain as evidence of your fitness. The form should not be more than 3 months old at the time of application.
MEDICAL REVIEW OF ML5 REPORT BY MCA MEDICAL ASSESSOR If there are ticks in Box 1, or if the doctor has made qualifying remarks in Section 8, he/she cannot complete the ML5 certificate pro-forma, and the Marine Office/RYA cannot issue your BML/RYA Certificate. However, in these circumstances you have the right to have your case reviewed and the Marine Office/RYA can refer your form to an MCA Medical Assessor for a final decision on your fitness to work on a boat.
For the purposes of medical review, you may wish to provide further information. This may include medical evidence from yourGP or a specialist consultant, if appropriate, or optometrist in relation to vision testing, as to your fitness to hold a BML/RYACertificate. Medical evidence should be submitted with this form to your local MCA Marine Office or the RYA in an envelopemarked "Private and Confidential" for forwarding to the Medical Administration Section of the MCA. You will also need to includeinformation about the work for which you need the Licence or Certificate; this should cover full details such as the class of vessel,the intended area of operation, type of vessel, number of passengers, duties, and whether there are other competent crew. Based on this evidence the MCA Medical Assessor will decide whether or not you meet the necessary requirements and if so, willissue an ML5 certificate restricting duties and/or type of operation, if necessary. It will then be for the MCA Marine Office / RYA todecide whether the BML / RYA Licence can be issued. PART A. PERSONAL DETAILS - to be completed by the APPLICANT (Please PRINT and use black ink)
Date of firstBML/ RYACertificate(if applicable)
YOU MUST SIGN THIS DECLARATION WHEN YOU ARE WITH THE DOCTOR WHO WILL BE FILLING IN PART B OF THIS REPORT
I authorise my doctors and specialists to release confidential information to MCA's Medical Assessor, if any matter affecting myfitness arises during the validity period of the BML/RYA Certificate or in connection with this application.
I also authorise the MCA Medical Assessor to advise the MCA of my fitness. Please move to PART B > MSF 4112 / REV0305 PART B. MEDICAL REPORT - to be completed by the Doctor Notes for the Doctor This medical report and certificate is required for applicants who are working on commercially operated small boats, including passenger boats, either on inland waters or at sea up to 60 miles from shore. In completing the form, you are asked to take account in broad terms of the environment in which the applicant will be working and to keep in mind that he or she is likely to have to fulfil some or all of the following duties :
to navigate the boat safely to safely berth and unberth the boat to help passengers on and off the boat to move and lift objects up to 30kg to operate equipment such as winches and to handle ropes to climb access ladders
In an emergency the applicant may be required to rescue
to tackle a fire to provide first aid to carry out an evacuation of the boat
IF, HAVING COMPLETED THE FOLLOWING REPORT THERE ARE NO TICKS IN BOX 1 AGAINST ANY OF THE QUESTIONS,AND YOU HAVE NO OTHER MEDICAL CONCERNS, PLEASE COMPLETE THE CERTIFICATE PROFORMA AT PART C ANDRETAIN A COPY FOR VERIFICATION PURPOSES. If any medical concerns are indicated on the form, you may be contacted in due course by an MCA Medical Assessor. SECTION 1 - Cardiac
a) Is there evidence of serious congenital heart disease requiring consultant
cardiological review at least every year?b) Is the applicant suffering from, or having attacks of angina of effort, or
receiving continuous treatment to prevent angina from manifesting itself?
c) Has the applicant suffered from myocardial infarction, unstable angina,
coronary artery bypass surgery or coronary angioplasty?
If YES - please answer the following:
ii) How long has elapsed since the event ?
iii) If the applicant remains on medication, give details
iv) Give details of any continuing symptoms / clinical signs of heart disease
d) Has the applicant uncontrolled complete heart block?
e) Has a cardiac pacemaker been implanted?
If YES, is the applicant attending a pacemaker clinic for at least annual review?
f) Has a cardioverter / defibrillator device been implanted?
g) Is there currently a serious disturbance of cardiac rhythm associated with
documented ischaemic or valvular heart disease?
h) Is the applicant in need of medication to prevent paroxysmal arrhythmia
(except for beta blockers, verapamil and digoxin)?
If YES, please give details MSF 4112 / REV0305 SECTION 1 - Cardiac (Continued)
i) Has the applicant undergone heart transplant or heart / lung tranplant surgery?
j) Has the applicant evidence of an aortic aneurysm that has not been successfully
SECTION 2 - Diabetes Mellitus
a) Is the applicant a diabetic requiring insulin injections?
SECTION 3 - Nervous System
a) Is the applicant liable to epileptic seizures or other sudden disturbances of the state of consciousness other than simple syncope?
(If there is any doubt, the opinion of a consultant neurologist should be obtained)
b) Is there a history of any major or minor stroke within the last 5 years?
c) Is there a history of Multiple Sclerosis or Parkinson's Disease?
d) Is there a history of malignant brain tumour in the last five years?
e) Is there a history of serious head injury with continuing symptoms?
f) Is there profound deafness that prevents communication by radio /telephone?
SECTION 4 - Psychiatric Illness
a) Has the applicant suffered from psychotic illness or required treatment for a
psychotic illness in the past two years?b) Has the applicant suffered from a serious mental disorder requiring treatment
with psychotropic medication in the last six months?
c) Is there any history of alcoholism during the last two years?
d) Is there any history of drug or substance misuse during the last two years?
SECTION 5 - Vision
a) Is there any evidence of a colour vision defect as assessed using Ishihara plates?
When testing, please ensure that aids to colour vision are not being worn.
b) Can the applicant read 6/6 on the Snellen Chart at six metres distance in at least
one eye with glasses or contact lenses if necessary ?
c) Can the applicant read 6/60 with at least one eye without any visual aid?
d) Has the applicant adequate field of vision with no progressive disease, in at least one eye?
e) Does the applicant have any other eye condition which could limit vision, either now or within
* Please give details for b), c), d), e) above
SECTION 6 - Malignant Growths
a) Does the applicant suffer from malignant disease likely to impair physical or mental
fitness to undertake duties in the foreseeable future?
SECTION 7 - Musculoskeletal Limitations and Obesity
a) Has the applicant reasonable physique to enable him to undertake intended duties and particularly to
physically assist other persons to evacuate a vessel in an emergency?
MSF 4112 / REV0305 SECTION 8 - Other Medical Conditions
Does the applicant suffer from any other relevant medical conditions not specified above? If so, please give details below (and overleaf if necessary)
SECTION 9 - Certification I certify that I have examined the applicant named in PART A and that my findings are recorded above in PART B of this report. There are no ticks in any Box 1, and I have completed the ML5 certificate proforma at PART C and retained a copy. * If No, please specify the Section numbers of Part B of this form where a Box 1 has been ticked Section (s)
Signature of Examining Medical Practitioner
Are you the applicant's General Practitioner ?
If you are not the applicant's GP, you should ask for photographic ID to confirm the identity of the person examined. Usual Medical Practitioner or Medical Adviser PART C. ML5 CERTIFICATE - to be completed by the Doctor (Copy to be retained by the Doctor for verification purposes) Notes for the completion of Part C
If you have not ticked any Box 1 in Part B of this form or made comments in Section 8, please complete the following certificate proforma at Part C, otherwise it should be left blank. PART C > An Executive Agency of the Department for Transport MSF 4112 / REV0305 SECTION 8 (Continued) MSF 4112 / REV0305 ML5 CERTIFICATE OF MEDICAL FITNESS based on the MARITIME AND COASTGUARD AGENCY (MCA) ML5 REPORT This is to certify that
has been assessed by me for medical fitness in accordance with the criteria specified by the MCA in theML5 form and all assessment ticks are in Box 2 (right hand column). I have not included any commentsaffecting fitness in Section 8 (Additional Notes)
*maximum 5 years from date of issue or 1 year for thoseover 65 years of age
** Endorsement not required for those not applying for a BML or RYA Certificate (See Note 4) on Page 1 of ML5 form)
MSF 4112 / REV0305 NOTES TO THE HOLDER OF THIS CERTIFICATE You must tell the issuing authority (MCA Marine Office or RYA) if, during the validity of your ML5 Certificate, you develop any condition or a disability which affects your fitness to work. This includes mental as well as physical conditions. Your BML/RYA Certificate will not be valid during your illness and you will need to obtain a new ML5 report/certificate once you have recovered. Those not requiring a BML or RYA Certificate do not need to have their ML5 certificates endorsed by the RYA or MCA Marine Office, but should retain them for inspection as necessary, noting the 5 year validity. An Executive Agency of the Department for Transport
The Orthopedic Center Bone Density Patient Questionnaire Name: _____________________________________ Street: _____________________________________ City: _____________________________________ Referred by:__________________________________ Primary Physician: __________________________ Other Physicians: _________________________________________________________________________ Is the
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