Form CG-719K Merchant Mariner Credential Medical Evaluation Report

U.S. DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD
CG-719K Rev. (01-09)

Merchant Mariner Credential
Medical Evaluation Report

OMB-1625-0040

• Detailed guidance on the medical and physical evaluation guidelines for merchant mariner credentials is contained in
Navigational and Vessel Inspection Circular (NVIC) 4-08.
• Additional information is also available at the National Maritime Center (NMC) Homeport website at:
http://homeport.uscg.mil/mmcmedical
• Additional information can also be obtained from NMC at: Commanding Officer, National Maritime Center, 100 Forbes
Drive, Martinsburg, WV 25404 or 1-888-I-ASK-NMC (1-888-427-5662)
Who must submit this form?
►

Applicants seeking an original, renewal or raise-in-grade credential are required to complete this form or its
equivalent, containing the same information, and submit it to the U.S. Coast Guard.

►

Guidance for required submission of this form is contained in Enclosure (1) of NVIC 4-08.
Instructions for Applicants

►

Applicants are required to provide the applicant information in section I, medication information in Section III, and
certification of medical conditions in Section IV.

►

Applicants are required to sign and date the certification in section I of this form attesting, subject to criminal
prosecution under 18 USC § 1001, that all information reported is true and correct to the best of their knowledge and
that they have not knowingly omitted or falsified any material information relevant to this form.

►

Applicants should also complete the release in section II of this form.
Privacy Act Statement

As required by Title 5 United States Code (U.S.C) 552a(e)(3), the following information is provided when supplying
personal information to the United States Coast Guard.
1.

Authority for solicitation of the information: 46 U.S.C. 2104(a), 7101[c]-(e), 7306(a)(4), 7313[c](3), 7317(a),
8703(b), 9102(a)(5).

2.

Principal purposes for which information is used:
a. To determine if an applicant is physically capable of performing their duties.
b. To ensure that a duly licensed or certified Physician (MD or DO) / Physician Assistant / Nurse Practitioner
conducts the applicant’s physical examination/certification and to verify the information as needed.

3.

The routine uses which may be made of this information:
a. This form becomes a part of the applicant's file as documentary evidence that regulatory physical
requirements have been satisfied and that the applicant is physically competent to hold a credential.
b. The information becomes part of the total credential file and is subject to review by Federal agency casualty
investigators.
c. This information may be used by the United States Coast Guard and an Administrative Law Judge in
determining causation of marine casualties and appropriate suspension and revocation action.

4.

Disclosure of this information is voluntary, but failure to provide this information will result in non-issuance of a
credential.

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 completing
this form is 20 minutes. You may submit any comments concerning the accuracy of this burden estimate or any
suggestions for reducing the burden to the Commandant (CG-543) United States Coast Guard. 2100 2nd Street SW.
Washington, DC 20593-0001.

Applicant Name: _______________________________________
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Page 2 of 9 of CG-719K Rev. 01-09

General Instructions for Medical Practitioner
1. The Coast Guard requires a physical examination and certification be completed to ensure that mariners:
►

Are of sound health.

►

Have no physical limitations that would hinder or prevent performance of duties (see below).

►

Are free from any medical conditions that pose a risk of sudden incapacitation, which would affect operating, or
working on vessels.

2. The medical practitioner must ensure a complete history and physical are conducted and make recommendations as
to the fitness of the applicant. Final approval of the mariner’s status rests with the U.S. Coast Guard.
3. All examinations, tests and demonstrations must be performed, witnessed or reviewed by a physician (Medical
Doctor (MD) or Doctor of Osteopathy (DO)) or nurse practitioner or a certified physician assistant licensed by a State
in the U.S., a U.S. possession, or a U.S. territory. The verifying medical practitioner (VMP) who performed the
examination must complete sections III, IV, VII, VIII, and IX of this form.
4. Detailed guidelines on medical conditions subject to further review are contained in NVIC 4-08 encl (3). Medical
practitioners should be familiar with the guidelines contained within this document. NVIC 4-08 may be obtained from
http://www.uscg.mil/hq/cg5/nvic/2000s.asp#2008 or by calling the nearest USCG Regional Examination Center, or
the National Maritime Center (http://homeport.uscg.mil/mmcmedical) at 1-888-IASKNMC (1-888-427-5662).
5. Verification of medications in section III of this form 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.
6. All applicants who require a general medical examination must be physically examined by the verifying medical
practitioner.
7. The verifying medical practitioner is not required to perform or witness every examination, test or demonstration.
These may be referred to other qualified practitioners; however, they must be reviewed to the satisfaction of the
verifying medical practitioner. The last page of this form contains a certification that the general medical
examination, vision and hearing tests, as well as the physical demonstration of competence as appropriate, have
been performed, witnessed or reviewed to the satisfaction of the verifying medical practitioner. Applicants who are
required to complete a general medical examination are also required to complete vision tests, and they may be
required to complete hearing tests and/or demonstrations of physical competence as appropriate. The verifying
medical practitioner must sign and date the certification where indicated. This signature attests, subject to criminal
prosecution under 18 USC § 1001, that all information reported by the verifying medical practitioner is true and
correct to the best of his/her knowledge and that the verifying medical practitioner has not knowingly omitted or
falsified any material information relevant to this form.
8. If the verifying medical practitioner is unable to determine the applicant’s physical ability, the applicant should be
referred to another healthcare provider who can properly evaluate and test physical abilities.
Instructions for Providing Proof of Identity
►

Applicants shall present acceptable proof of identity to the medical practitioner conducting examinations.

►

Medical practitioners must verify the identity of applicants before conducting examinations.

►

Proof of identity shall consist of one current form of valid government issued photo identification.

►

The following credentials are examples of acceptable proof of identity:
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 or Merchant Mariner’s
Document/Merchant Mariner Credential.

Applicant Name: _______________________________________
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Page 3 of 9 of CG-719K Rev. 01-09

Section I - Applicant Information
Last Name:

First Name:

Middle Name:

Age:

Date of Birth (MM/DD/YYYY):

Social Security Number:

Suffix: (Jr., Sr., III)

Applicant Certification (to be signed by applicant)
My signature below attests, subject to prosecution under 18 USC 1001, that all information that I have reported is true
and correct to the best of my knowledge, and that I have not knowingly omitted to report any material information
relevant to this form.
Date:

Printed Name:
Signature:

How do you wish to be contacted? (phone, e-mail, letter, fax)

Please include contact information below:

Section II – Release
I hereby authorize the verifying medical practitioner (VMP), 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 credential(s) for maritime service.
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 credential(s)
for maritime service. This authorization will remain in effect until the Coast Guard determines whether to issue me the
requested credential(s) for maritime service, but no longer than one year.
I have read and understand the following statement about my rights:
►

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.

►

Upon request, I may see or copy the information described in this release.

►

I am not required to sign this release to receive my medical evaluation.

Applicant:
Name (Printed):

Signature:

Applicant Name: _______________________________________
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Page 4 of 9 of CG-719K Rev. 01-09

Section III - Medications (must be completed by applicant and reviewed by verifying medical practitioner)
Credential applicants who are required to complete a general medical exam are required to report all prescription
medications prescribed, filled or refilled and/or taken within 30 days prior to the date that the applicant signs the CG
719K or approved equivalent form. In addition, all prescription medications, and all non-prescription (over-the-counter)
medications including dietary supplements and vitamins, that were used for a period of 30 or more days within the last
90 days prior to the date that the applicant signs the CG-719K or approved equivalent form, must also be reported.
The information reported by the applicant must be verified by the verifying medical practitioner or other qualified
medical practitioner to the satisfaction of the verifying medical practitioner to include the following two items.
1.
Report all medications (prescription and non-prescription), dietary supplements, and vitamins.
2.
Include dosages of every substance reported on this form, as well as the condition for which each substance
is taken.
Additional sheets may be added by the applicant and/or qualified medical practitioner if needed to complete this
section (include applicant name and date of birth on each additional sheet).
If none, check “NONE.”
NONE

Section IV - Certification of Medical Conditions (must be completed by applicant and reviewed by
verifying medical practitioner)
Applicants must report their relevant medical conditions to the best of their knowledge, and the verifying medical
practitioner must verify the medical conditions, using the table below. Check "yes" if the applicant has had a previous
diagnosis or treatment of the condition by a healthcare provider, or if the applicant is currently under treatment or
observation for the condition, or if the condition is present regardless of treatment.
If the verifying medical practitioner, or any other health care provider to the satisfaction of the verifying medical
practitioner, discovers a condition not reported by the applicant, he/she must check "yes" in the appropriate block and
explain in the remarks.
The verifying medical practitioner must address all reported relevant conditions in detail in this Section. This
detailed explanation should include, at a minimum, identification of the condition, approximate date of diagnosis, any
limitations, whether the condition is controlled, the prognosis and any additional information as appropriate, referring to
the evaluation data listed in enclosure (3) of NVIC 4-08 for each condition.
Additional sheets may be added by the applicant and/or verifying medical practitioner if needed to complete this
section of the form. (include applicant name and DOB on each additional sheet).
To the best of the applicant’s knowledge, does the applicant have, or have ever suffered from, any of the
following?
If YES, the applicant must PROVIDE THE TEST RESULTS AND/OR RECORDS AS INDICATED, referring to the
evaluation data listed in enclosure (3) of NVIC 4-08 for each condition. Documentation of evaluation data specified in
this table for all applicable medical conditions potentially requiring further review should be submitted with each
application, unless otherwise specified by the NMC. Mariners, including first class pilots and those individuals “serving
as” pilots (as well as Great Lakes pilots) who are required to submit annual physical examinations to the Coast Guard,
may be issued a letter by the NMC specifying the extent of the evaluation data, if any, that should be submitted to the
Coast Guard for any medical conditions that have been previously reported to, and evaluated by, the NMC.
The verifying medical practitioner shall make comments on all answers marked “yes” on the following page for which no
evaluation data has been submitted. If known to the VMP, the VMP may comment that a condition has been previously
reported on a prior CG-719K, but only for those CG-719Ks submitted after December 31, 2008, and only for those
conditions which have not changed since the condition was previously reported on a prior CG-719K
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Page 5 of 9 of CG-719K Rev. 01-09

1.

Identify the Condition

3.

Is Condition Controlled?

5.

Prognosis

2.

List Any Limitations

4.

Approximate Date of Diagnosis

6.

Additional Information

YES

NO

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.

Condition #

YES
Ear surgery,
Hearing loss, hearing aid
Impaired speech or stuttering
Deformities of face
Open tracheostomy
Poor vision
History of eye disease or injury
History of eye surgery
Abnormal color vision
Glaucoma
Asthma
Emphysema or COPD
Collapsed lung/pneumothorax
Irregular heart beat
Heart murmur or valve replacement
Chest pain or angina
Heart attack/ myocardial infarction
Congestive heart failure
Heart surgery/stent/angioplasty
Pacemaker or defibrillator
Any other heart condition
High blood pressure/hypertension
Aneurysm or blockages
Pulmonary embolus or blood clots
Gastrointestinal bleeding or ulcers
Crohn’s disease or ulcerative colitis
Hepatitis or jaundice
Gallbladder problems or stones
Intestinal surgery
Any form of cancer
Anemia
Hemophilia or polycythemia
Any other blood disorders
Thyroid disease
Diabetes
HIV or AIDS
Lymphoma or leukemia
Tuberculosis
Neurofibromatosis
Skin tumors or cancer
Scleroderma
Lupus
Kidney transplant or dialysis
Kidney disease or cancer

45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.

NO
Kidney stones
Protein/sugar/blood in urine
Back surgery or injury
Ruptured/herniated disc
Fractures requiring surgery
Limitation of any major joint
Bone or joint surgery
Dislocated joint
Recurrent neck or back pain
Swollen or painful joint
Arthritis or bursitis
Trick or locked knee
Amputation or prosthesis
Carpal tunnel
Difficulty walking or climbing
Sciatica or nerve pain
Other bone/joint disorder
Motion/sea sickness
Impaired balance, or balance disorder or difficulty
Vertigo or dizziness
Numbness or paralysis
Head injury or skull fracture
Seizures or epilepsy
Recurrent headaches
Narcolepsy
Sleep apnea
Restless leg
Fainting spells or loss of consciousness
Stroke or TIA
Brain tumor
Other brain or nerve disease
ADD, ADHD, or bipolar
Depression
History of suicide attempt
Schizophrenia
Anxiety
Alcohol or substance abuse
Loss of memory or amnesia
Other psychiatric disease or counseling
Sleepwalking
Bedwetting since age 12
Sex change
Allergic reactions
Any other disease, surgery or hospitalization

Comment

Applicant Name: _______________________________________

Date of Birth:____________________________

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Page 6 of 9 of CG-719K Rev. 01-09

Section V (a) – Visual Acuity
This section must be completed by the verifying medical practitioner, or any other healthcare provider to the satisfaction of
the verifying medical practitioner see encl 5 of NVIC 4-08. Additional information must be reported in Section VII. If
corrective lenses are required to meet the standard, both corrected and uncorrected vision must be tested.
Distant Uncorrected

Distant Corrected To

Right:

20

/

Right:

20

/

Left:

20

/

Left:

20

/

Field of Vision
This applicant must have a 100-degree
horizontal field of vision.

Normal
Abnormal

Section V (b) – Color Vision
The following color sense testing methodologies are
acceptable:
AOC (1965) – (6 or fewer errors on plates 1-15)

Titmus Vision Tester / OPTEC 2000 – (No errors on six
plates)

AOC-HRR (2nd Edition) – (No errors in test plates 7-11)

Farnsworth Lantern (colored lights) Test per instruction
booklet.

Richmond (1983) – (6 or fewer errors)

Optec 900 (colored lights) Test per instruction booklet.

Ishihara pseudoisochromatic plates test, 14 plate (5 or
less errors), 24 plate (6 or less errors) 38 plate (8 or
less errors)

An alternative test approved by the Coast Guard
(indicate test)

The verifying medical practitioner must indicate test used and results (number of errors). Additional information must be
reported in Section VII. Color sensing lenses (e.g. X-Chrome) are prohibited.
Color Vision:

Normal Color Vision

Abnormal Color Vision

Number of Errors _______________

Section VI – Hearing
Normal

Abnormal Hearing

Hearing Aid Required

If abnormal hearing or hearing aid required, perform audiogram or functional speech discrimination test.
An applicant with normal hearing does not need to complete either the audiometer test or the functional speech
discrimination test. The verifying medical practitioner, in consultation with any other healthcare provider he/she deems
appropriate, determines whether the audiometer and/or functional speech discrimination tests are necessary. If hearing is
abnormal or a hearing aid is required, refer to enclosure (5) of NVIC 4-08 for guidance.
If audiometric testing is required, the audiometer test should include testing at the following thresholds, 500Hz, 1,000 Hz,
2,000 Hz and 3000 Hz. The frequency responses for each ear are averaged to determine the measure of an applicants
hearing ability. The Applicant should demonstrate an unaided threshold of 30dB in each ear.
Additional information must be reported in Section VII.
Audiometer Threshold Value

500Hz

1,000Hz

2,000Hz

3,000Hz

Right Ear (Unaided)
Left Ear (Unaided)
Right Ear (Aided)
Left Ear (Aided)

Functional Speech
Discrimination Test @ 55dB

Right Ear (Unaided):

%

Right Ear (Aided)

%

Left Ear (Unaided):

%

Left Ear (Aided)

%

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Page 7 of 9 of CG-719K Rev. 01-09

Section VII (a) - Physical Information
This section to be completed by the verifying medical practitioner, or other medical staff to the satisfaction of the verifying
medical practitioner. Additional information must be reported in Section VII.
Height (inches only):

Weight (lbs):

Body Mass Index (BMI): Gender:

Pulse Resting:

Initial Blood Pressure:

Repeat Blood Pressure (if needed):

Section VII (b)– Physical Exam (must be completed by verifying medical practitioner)
#

Normal

Abnormal

System/Organ

#

Normal

Abnormal

System/Organ

1.

Head, Face, Neck, Scalp

10.

Skin

2.

Eyes / Pupils / EOM

11.

Lymphatic

3.

Mouth And Throat

12.

Neurologic

4.

Ears / Drums

13.

Vascular System

5.

Lungs And Chest

14.

Genital-Urinary System

6.

Heart

15.

Hernia

7.

Abdomen

16.

Missing extremities / Digits

8.

Upper / Lower Extremities

17.

General / Systemic

9.

Spine / Musculoskeletal

Please make numbered comments on abnormal systems/organs:

Section VIII - Demonstration of Physical Ability (to be completed by the verifying medical practitioner)
► If the examining 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 40.0 or higher, the practitioner shall require that the applicant
demonstrate the ability to meet the guidelines. This does not mean, for example, that the applicant must actually don an
exposure suit, pull an uncharged 1.5 inch diameter 50’ fire hose with nozzle to full extension, or lift a charged 1.5 inch
diameter fire hose to fire fighting position. Rather, the medical practitioner may utilize alternative measures to satisfy
himself or herself 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 Section IX.
► All practical demonstrations, if required, should be performed by the applicant without assistance. Any prosthesis
normally worn by the applicant, and 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).

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Page 8 of 9 of CG-719K Rev. 01-09

►

If the verifying 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 all medical practitioners may not have the
equipment necessary to test all of the tasks as listed. Equivalent alternate testing methodologies may be used. For
further information, see enclosure (2) of NVIC 4-08.

►

If the applicant is unable to perform any of the following functions, the examining 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 Section IX.
List of tasks considered necessary for performing ordinary and emergency response shipboard functions:
Shipboard Tasks,
Related Physical Ability:
The examiner should be satisfied that the applicant:
function, event or
condition:
Routine Movement on
Maintain Balance (equilibrium).
Has no disturbance in sense of balance.
slippery, uneven, and
unstable surfaces.
Routine access
Climb up and down vertical ladders and Is able, without assistance, to climb up and down vertical
between levels.
stairways.
ladders and stairways.
Is able without assistance, to step over a door sill or
Routine movement
Step over high door sills and coamings,
coaming of 24 inches (61 centimeters) in height. Able to
between spaces and
and move through restricted accesses.
move through a restricted opening of 24 inches.
compartments.
Is able, without assistance, to open and close watertight
Open and close
Manipulate mechanical devices using
doors that may weigh up to 55 pounds (25 kilograms).
watertight doors, hand
manual and digital dexterity, and
Should be able to move hands/arms to open and close
cranking systems,
strength.
valve wheels in vertical and horizontal directions; rotate
open/close valve.
wrists to turn handles. Reach above shoulder height.
Is able, without assistance, to lift at least a 40 pound
Handle ship’s stores.
Lift, pull, push, and carry a load.
(18.1 kilogram) load off the ground, and to carry, push or
pull the same load.
Crouch (lowering height by bending
knees); kneel (placing knees on ground);
General vessel
and stoop (lowering height by bending at Is able, without assistance, to grasp, lift and manipulate
maintenance.
various common shipboard tools.
the waist). Use hand tools such as
spanners, valve wrenches, hammers,
screwdrivers, pliers.
Emergency response
Crawl (the ability to move the body with
Is able, without assistance, to crouch, keel and crawl,
procedures, including
hands and knees); feel (the ability to
and to distinguish differences in texture and temperature
escape from smokehandle or touch to examine or determine
by feel.
filled spaces.
differences in texture and temperature).
Is able, without assistance, to intermittently stand on feet
Stand a routine watch. Stand a routine watch.
for up to four hours with minimal rest periods.
React to visual alarms
Fulfills the eyesight standards for the merchant mariner
and instructions,
Distinguish an object or shape at a
credential(s) applied for. See footnote 1 of this table &
emergency response
certain distance.
enclosure (5) of NVIC 4-08.
procedures.
React to audible alarms
Fulfills the hearing capacity standards for the merchant
and instructions,
Hear a specified decibel (dB) sound at a
mariner credential(s) applied for.
emergency response
specified frequency.
procedures.
Make verbal reports or
call attention to
Describe immediate surroundings and
Is capable of normal conversation.
suspicious or
activities, and pronounce words clearly.
emergency conditions.
Is able, without assistance, to pull an uncharged 1.5 inch
diameter, 50’ fire hose with nozzle to full extension, and
Participate in
Be able to carry and handle fire hoses
firefighting activities.
and fire extinguishers.
to lift a charged 1.5 inch diameter fire hose to fire fighting
position.
Has the agility, strength and range of motion to put on a
Abandon ship.
Use survival equipment.
personal flotation device and exposure suit without
assistance from another individual.
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Page 9 of 9 of CG-719K Rev. 01-09

Section IX – Verifying Medical Practitioner Recommendation
Recommended
Competent

Not Recommended Competent (explain in
comments)

Needing Further Review
(explain in comments)

Comments on
Recommendation:

Verifying Medical Practitioner:
This signature attests, subject to criminal prosecution under 18 USC § 1001, that all information reported by the verifying
medical practitioner is true and correct to the best of his/her knowledge and that the verifying medical practitioner has not
knowingly omitted or falsified any material information relevant to this form.
Name (Printed):

Signature:
Date:

U.S. Dept. of Homeland Security, USCG, CG-719K, Rev. 01-09

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