HTML Preview Medical Examination Report page number 1.
Permanent address
MEDICAL EXAMINATION REPORT
You should complete this section before you go for your medical
examination.
You must take a suitable means of identication (passport,
Australian driving licence) with you to the examination.
PART A - TO BE COMPLETED BY APPLICANT
Name
Family name
Given name(s)
Date of birth
Female
Do you drink alcohol?
Do you smoke tobacco?
If no, have you smoked in the past?
Personal history
Have you been absent from work due to sickness or injury for
more than 14 consecutive days over past two years?
If yes, give details
Are you in good health now?
PRIVACY NOTE
The Australian Maritime Safety Authority (AMSA) is collecting the
information on this form for the purpose of assessing your medical
tness for duty at sea and for AMSA audit purposes. The collection of the
information is required, authorised or directly related to the Navigation
Act 2012 (the Act) and the Marine Orders made under it. It will be used
for purposes related to the Act and Marine Orders and will be treated
in accordance with the Australian Privacy Principles. This information
may be exchanged between AMSA, your examining medical ofcer,
your treating medical practitioner and/or any medical panel convened to
assess your tness for duty at sea. Failure to provide the information may
result in the transaction not being processed. To contact us, or for more
information on how to access or correct your personal information, how
to make a privacy complaint, or how your information may be used or
disclosed, visit AMSA’s privacy policy at www.amsa.gov.au/privacy/
Have you ever been declared unt for duty at sea?
If yes, state when, for how long and for what reason
Have you ever been signed off as sick or repatriated from a ship?
Has your Certicate of Medical Fitness ever been restricted or
cancelled or have you ever been declared unt?
Have you ever had any surgical or chiropractic treatment?
Are you taking any medications at present?
NOTE: If you wear glasses, corneal or contact lenses, bring them
with you to the examination. CHROMAGEN LENSES MUST NOT
BE WORN
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Male
Seafarer I.D.
Department/Position on board vessel
Other (specify)
If yes, how much and how often?
If yes, give details
If yes, give details
If yes, give details
AMSA 232 (6/16) 1 of 4
Deck Ofcer (Coastal Pilot / Master / Chief Mate / Mate /
Watchkeeper Deck)
Integrated Rating* (Chief / Integrated Rating*)
Engineering Ofcer (Engineering* / Engineer Watchkeeper*
/ Electro-Technical Ofcer*)
Catering (Marine Cook)*
Do you have or have you had any eye disorder or injury?
* Denotes Hepatitis A arrangements apply
Yes No
Yes No
/ /
dd mm yyyy
Indeterminate
Rating-Deck (Rating - Navigational Watch / Able Seafarer -
Deck)
Rating-Engineering* (Rating - Engine Room Watch* / Able
Seafarer - Engine*)
Email
Phone