ISSUED ON BEHALF OF THE DEPARTMENT OF SHIPPING

GOVERNMENT OF THE PEOPLE'S REPUBLIC OF BANGLADESH

Form No: SMC SL NO:

1 2 = lA ?.1 - 0 2I S
SEAFARER MEDICAL CERTIFICATE

This certificate is issued in accordance with Bangladesh Merchant Shipping Ordinance, 1983 and Bangladesh Merchant Shipping
Officers and Ratings Training, Certification, Recruitment, Work I{ours and Watch keeping Rules,2011 in cornpliance with the
Intcrnational Convention on Standards of Training Cerlificate and Watch keeping for Seafarers,7978 as amended (STCW'7S) and
Regulation 1.2 of the Maritime Labour Convention, 2006

SEAFARER INFORMATION:
Name: Last. HIIYIEL .....r i r st..il9.!!1.Y.m.2 At. ..... ..MiddIe.. ft.$13Y.!: ...f olnlN
Date of Birth: (DD/MM/YYYY). ........13-:..97.-..1.?..?6... Gender: (vlfte/remate).......11q19=
N ati ona I ity : ..... 0.8.lq.h.faD F..€lt Passpo rtlN I D No :.. SN ..97,.A -q.25p...

occupation: oeck/Enfin elCaterinslother (specify)..F.{.8.!Ie.......... nank.....3flT.t*.ft

Fli-her's/ Husband's name,..$9nn!L11E0....tlF-lFt.....V.pP!11....T989.r.0FK........
M ot h e r's N a m e : ... ...$n hl. m.l{P. fl....... ilF;LNNA
Mailing address: House No: . Street/Road No: .....
Locality/Vil P.O
p.s:...ffl.8.1:fl.n.gn D istri ct : .....p.. n.4n !,. e.V. K...

DECTARATION OF THE RECOGNIZED MEDICAL PRACTITIONER:

I am duly authorized by the Department of Shipping, Government of the People's Republic of Bangladesh and confirm
the followings;
L Confirmation that identification documents were checked at the point of examination \.YtS/NO
2. Hearing meets the standards in section A-l/9 .zYES/NO
3. Unaided hearing satisfactory? -zYES/NO
4. Visual acuity meets standards in section A-l/9? ",rYES/NO
5. Colour vision meets standards in section A-l/9? -.{eSlnO
Date of last colour vision test ? 2..08[.20?].....
6. Fit for lookout duties? -:4ES/NO
7. ls the seafarer free from any medical coniition likely to be aggravated to renderby service at sea or
the seafarer unfit for service or to render the health of any other persons on board? ./YES/NO
8. Any limitations or restrictions on fitness? : YES/Norz
lf YES, specify limitations or restrictions

Duties:
Location/Vessel
Medica

9. Medical fitness category: o restriction Fit-Subject to restrictions Unfit

10. Date of examination/lssue (DD/M M/YYIYd

72
11. Date of expiry (DD/MM/YYYY)
ri. IUIJ
"No more than 2 years from the date of ion"

I have read the contents of the certificate

and have been informed of the right to
Dr. ATM Anwarul Haque
MBBS, CCD (BIRDEM)
review. Reo. no. A279Az
4;"/
Seafarer's Signature
* fs Per * Authoriieo by DOS (BD)
lVlarine Health Care
Dh al<.a
Name & ature of the Practitioner:
 MEDICAL Rf,QUIREMENTS
All applicants for an olficer certificate, Seafarer's Identification and Record Book or cerlification ofspecial qualifications shall be required
to have a physical examination reported on this Medical Form completed by a cerlificated physician. The completed medical form must
accompany the application for officer certificate, application for seafarer's identity document, or application for certification of special
qualifications. This physicai examination must be carried out not more than 24 months prior to the date of making application for an
officer cefiificate, certification of special qualifications 0r a seafarer's book. The examination shall be conducted in accordance
with the Intemational Labor Organization World Health Or:ganization. GtLidelines for Conducting Pre'sea and Periodic Medical
Fitness Examinations for Seafarers (ILO|WHO|D.2|1997) . Such proof of examination must establish that the applica-nt is in satisfactory
physical and mental condition for the specific duly assignment undefiaken and is generally in possession of all body faculties necessary in
fulfil1ing the requirements of the seafaring profession.

In conducting the examination, the certified ph,risician should. rvhere appropliate, examine the seafarer's previous medical records
(including vaccinations) and information on occupational history, noting any diseases, including alcohol or drug-related problems and/or
injuries. In addition, the foliowing minimum requirements shall apply:
(a) Hearing
r A1l applicants must have hearing unimpaired for normal sounds and be capabie of hearing a whispered voice in better ear at l5
feet (4.57 m) and in poorer ear at 5 feet ( I .52 m).
(b) Eyesight
r Deck officer applicants must have (either with or without glasses) at least 616 12012010.00) vision in one eye and at least 5/12
t20l401 (0.50)in the other. Ifthe applicant wears glasses, he must have vision without glasses ofat ieast 6/45 [20ii50]
(0.13) in
both eyes. Deck officer applicants must also have normal color perception and be capable of distinguishing the colors red,
green, blue and yellow.
. Engineer and radio officer applicants must have (either with or without glasses) at least 6/9 [20n0] (0.67) vision in one eye and
at least 6/15 [20150] (0.40) in the other. If the applicant wears glasses, he must have vision without glasses of at least 6/60
12012001 (0.10) in both eyes. Engineer and radio officer applicants must also be able to perceive the colors red,
yel1ow and
' green.
(c) Dental
. Seafarers must be free from infections of the mouth cavity or gums.
(d) Blood Pressure
o An applicant's blood pressure must fal1 within an average range, taking age into consideration.
(e) Voice
. Deck,Navigational officer applicants and Radio officer applicants must have speech which is unimpaired for normal '"'oice
communication.
(0 Vaccinations
r A11 applicants shall be vaccinated according to the requirements indicated in the WHO publication, Intemational Travel and
Health, Vaccination Requirements and Health Advice. and shall be given advice by the certified physician on immunizations. if
new vaccinations are given, these shall be recorded.
(g) Diseases or Conditions
. Applicants afflicted with any of the following diseases or conditions shall be disqualified: epilepsy. irisanity, senility,
alcoholism, tuberculosis, acute venereal disease or neurosyphilis. AIDS, and/or the use of narcotics. Applicants diagnosed with,
suspected of, or exposed to any communicable disease transmittable by food sha11 be restricted from working with food or in
food - related areas until symptom-free for at least 48 hours.
(h) PhysicalRequirements
. Applicants for able seaman, bosun, GP-1, ordinary seaman and junior ordinary sealnan must meet the physicai requirements for
a declc/navigational olfi cer's ceftifi cate.
. Applicants for fireman/water tender, oiler/motonnan, pump man, electrician, wiper, and tanker man and survival craft/rescue
boat crewman must meet the physical requirements for an engineet officer's certificate.

IMPORTANT NOTE:
An applicant who has been refused a medical cefiificate or has had a limitation imposed on his,&er ability to work, sha11 be given the
opportunity to have an additional examination by another medical practitioner or medical referee who is independent of the shipowner or
of any organization of shipowners or seafarers.
Medical examination reports shall be marked as and remain confidential with the applicant having the fight of a copy to his/her reporl. The
medical examination reporl shall be used only for determining the fitness of the seafarer for work and enhancing health care.

DETAILS OF' MEDICAL EXAMINATION

(To be completed by examining physician; , the examining physician may attach a form similar or model
provided in Appendix 1)
1. Complete Physical Examination
2. Investigation: a. CBC b. ESR c. X-Ray, VDtLt- Dr. ATM Anwarul Haque
MBBS, CCD (BIRDE[\4)
Req. no. A279A2
Marine Dhaka
F{