CG-719K Merchant Mariner Credential Medical Evaluation Report

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DEPARTMENT OF HOMELAND SECURITY
U.S. Coast Guard

OMB-1625-0040
Expires 6/30/12

Merchant Mariner Medical Evaluation Report
Section I: Applicant Information - To be completed by the Applicant and reviewed by the Medical Practitioner
Last Name
Age

First Name
Social Security No. (XXX-XX-XXXX)

Occupation:

Deck

Engineer

Food Handler

STCW

Middle Name

Suffix (Jr., Sr., III)

Reference No. (If applicable)

Female

Male

Sex:

Date of Birth (mm/dd/yyyy)

Application Type:
Other

Original
Renewal

Specify:

Raise In Grade to

Section II: Applicant Certification and Release - To be completed by the Applicant and reviewed by the Medical Practitioner
Third Party Release:

By checking the following box, I am authorizing release of information to the third party as indicated below. If a selection is made, please provide the name of
organization or third party, address, and phone number. Additional third party release information can be attached separately.
Act on my behalf in all matters pertaining to the
processing of my current USCG medical certificate
application

Name of Organization or Third Party:
Organization Point of Contact (if applicable):
Address:
City:
(

State:
)

Phone Number

Zip Code:

--

(000) 000-0000

My signature below attests, subject to prosecution under 18 USC 1001, that all information provided by me on this application form is complete and true to the best of my
knowledge, and I agree that it is to be considered part of the basis for issuance of any medical certificate to me. I have not knowingly omitted any material information relevant to this
form. I have also read and understand the Privacy Act Statement that accompanies this form.
I hereby authorize the medical practitioner, who has signed the certification on page 6 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 medical certificate 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 medical certificate for maritime service. This authorization will remain in effect until the Coast Guard determines
whether to issue me the requested medical certificate 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 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.

Name

(First Name)

(M.I.)

(Last Name)

Signature

Date (mm/dd/yyyy)

Section III: Medications - To be completed by the Applicant and reviewed by the Medical Practitioner
The information reported by the applicant must be verified by the medical practitioner to include the following two items.
1. Report all medications (prescription and non-prescription), dietary supplements, minerals, performance enhancing substances, and vitamins prescribed,
filled, and/or taken within the last 30 days or used for 30 or more days within the last 90 days.
2. Include dosage and frequency taken of every substance on this form, as well as the condition for which each substance is taken.
Additional sheets may be added by the applicant and/or medical practitioner if needed to complete this section. (Include applicant name and date of birth on each
additional sheet.)
If none, check "NONE".

CG-719K (06/12)

NONE

Applicant Name:
(First Name, MI, Last Name)

Date of Birth:
(mm/dd/yyyy)
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Section IV: Medical Conditions
Have you ever had, been treated for, or do you presently have any of the following conditions?
Yes

No 1. Eye/vision problems except glasses

Yes

No 2. Ear/nose/throat problems or other ENT problems/surgery

Yes

No 3. High or low blood pressure

Yes

No 4. Heart or vascular disease of any kind

Yes

No 5. Heart surgery and/or implanted devices (pacemaker,
defibrillator, etc.)
No 6. Lung disease of any type (asthma, bronchitis,emphysema, etc.)

Yes

Yes

No 21. Frequent motion sickness requiring medication

Yes

No 22. Stroke or Transient Ischemic Attack (TIA), brain tumor or other
brain disorder
23.
Any
neurologic disorder or nerve problems including numbness
No
and/or paralysis, not listed above

Yes
Yes

No 24. Attention Deficit Disorder with or without Hyperactivity

Yes

No 25. Anxiety, depression, bipolar disorder, adjustment disorder,
PTSD, or schizophrenia

Yes

No 26. Suicide attempt or Ideation

Yes

No 27. Taken medications, drugs, over-the-counter medications,
supplements, or any substance to improve attention, behavior,
or physical performance
28.
Evaluation, treatment, or hospitalization for alcohol or
No
substance use, abuse, addiction, or dependence (including
illegal drugs, prescription medications, or other substances)
29.
Any
other psychiatric disorder, mental health evaluation/
No
hospitalization, or psychological counseling not listed above.

Yes

No 7. Any blood disorder (anemia, hemophilia, blood clots,
polycythemia, etc.)
No 8. Diabetes, glucose intolerance, or sugar in urine

Yes

No 9. Thyroid problem

Yes

No 10. Stomach, liver, or intestinal disorder

Yes

No 11. Kidney problems/stones or blood in urine

Yes

No 12. Any other urinary or bladder problems not listed above

Yes

No 13. Skin disorder or problem

Yes

No

Yes

No 15. Infectious/contagious disease

Yes

Yes

No 16. Any sleep problems: Obstructive Sleep Apnea, Restless Leg
Syndrome, Narocolepsy, Shift Work Sleep Disorder, Insomnia, etc.

Yes

No 33. Medical rejection or discharge by military or life/health insurance

Yes

No 17. Epilepsy, fits, or seizures

Yes

No 34. Any hospital admissions not listed above

Yes

No 18. Loss of consciousness or memory

Yes

Yes

No 19. Frequent or severe headaches

Yes

Yes

No 20. Dizziness/fainting spells/balance problems

Yes

Yes

14. Allergies or allergic reactions to any substance, medication,
or food.

Yes
Yes
Yes
Yes

No 30. Back pain, joint problems, or orthopedic surgery
No 31. Amputation, prosthesis, or use of ambulatory devices (cane,
walker, braces, etc.)
No 32. Fractures, recurrent dislocations or limitation of motion of
any joint

35. Any diseases, surgeries, cancers, illnesses, or disabilities not
listed on this form.
36.
Have
you ever been signed off as sick or repatriated
No
from a ship?
37. Have you ever been denied a merchant mariner
No
credential for medical reasons?
No

Comments: For each "YES" answer, please provide the following: medical condition number, diagnosis/ICD code, details, dates, treatment given,
and current medical/functional status. Additional sheets may be added as needed being sure applicant name and date of birth appear on each
additional sheet.
Number Additional Information

Applicant Name:
(First Name, MI, Last Name)

Date of Birth:
(mm/dd/yyyy)
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REPORT OF MEDICAL EXAMINATION
The following sections must be completed by the Medical Practitioner
Section V: Vision

The 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.

a. Visual Acuity
Distant Corrected To

Distant Uncorrected
Right: 20

/

Right: 20

/

Left:

/

Left:

/

20

20

Field of Vision

This applicant must have a 100-degree horizontal field of vision.
Normal
Abnormal

b. Color Vision

The following color sense testing methodologies are acceptable:

AOC (1965) - (6 or fewer errors on plates 1-15)

Ishihara pseudoisochromatic plates test, 14 plate (5 or less errors)

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

Ishihara pseudoisochromatic plates test, 24 plate (6 or less errors)

HRR PIP (4th Edition) - (No errors in test plates 5-10)

Ishihara pseudoisochromatic plates test, 38 plate (8 or less errors)

Richmond (1983) - (6 or fewer errors)
Titmus Vision Tester/OPTEC 2000 - (No errors on 6 plates)

Farnsworth D-15 Hue Test (attach test results)
(Engineer/radio/tankerman/MODU only)

Optec 900 (colored lights) Test per instruction booklet.

Farnsworth Lantern (colored lights) Test per instruction booklet
Dvorine pseudoisochromatic 15 plate test (6 or less errors)

Color Vision Testing Results:
Passed

Failed

Number of Errors:

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

Mariner is able to distinguish red, green, blue, and yellow:
No
Yes

Section VI: Hearing
(a) An applicant with normal hearing by forced whispered voice ≥ 5 feet with or without hearing aids does not need to complete either the audiometer test or the
functional speech discrimination test.
(b) If hearing is abnormal, then perform either a functional speech discrimination test at 55 dB or an audiogram documenting thresholds and averages as
indicated below. Both aided and unaided values should be recorded for applicants requiring hearing aids.
(c) All applicants with an unaided threshold > 30dB in the better ear should have functional speech discrimination testing performed at 55dB.
(d) Refer to Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials from the NMC website (http://www.uscg.mil/nmc/medical.asp) for
further guidance. Report any additional information or comments in Section VII.

Normal Hearing

Abnormal Hearing

Functional Speech
Discrimination Test @ 55dB

Audiometer
Threshold Value
500Hz

1,000Hz

2,000Hz

Hearing Aid Required

3,000Hz

Average

Right Ear (Unaided):

%

Left Ear (Unaided):

%

Right Ear (Aided):

%

Left Ear (Aided):

%

Right Ear (Unaided)

Left Ear (Unaided)

Right Ear (Aided)

Left Ear (Aided)

Applicant Name:
(First Name, MI, Last Name)

Date of Birth:
(mm/dd/yyyy)
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Section VII: Physical Examination
This section should be completed by the medical practitioner or other medical staff to the satisfaction of the medical practitioner.
Please make comments in the space provided on any item indicated as an "abnormal" system/organ.

Height (inches only):

Weight (lbs):

Pulse Resting:

Initial Blood Pressure:

1. Head, Face, Neck, Scalp
Abnormal
Normal
2. Eyes / Pupils / EOM
Normal

Abnormal

3. Mouth and Throat
Normal

Abnormal

4. Ears / Drums
Normal

Abnormal

5. Lungs and Chest
Normal

Abnormal

Body Mass Index(BMI):
Repeat Blood Pressure
(if needed):

Additional Medical Comments
Item Additional Information

6. Heart
Normal

Abnormal

7. Abdomen
Normal

Abnormal

8. Upper / Lower Extremities
Abnormal
Normal
9. Spine / Musculoskeletal
Abnormal
Normal
10. Skin
Normal

Abnormal

11. Lymphatic
Normal

Abnormal

12. Neurologic
Normal

Abnormal

13. Vascular System
Normal

Abnormal

14. Genitourinary System
Abnormal
Normal
15. Hernia
Normal

Abnormal

16. Missing Extremities / Digit
Abnormal
Normal
17. General / Systemic
Normal

Abnormal

Applicant Name:
(First Name, MI, Last Name)

Date of Birth:
(mm/dd/yyyy)
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Section VIII: Demonstration of Physical Ability
1. If the 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 firefighting 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 the Comments section provided below.
2. All practical demonstrations, if required, should be performed by the applicant without assistance. Any prosthesis normally worn by the applicant, and any 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).
3. If the 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, check the Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials (http://www.uscg.mil/nmc/medical.asp).
4. If the applicant is unable to perform any of the following functions, the medical 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 Comments section provided below.

LISTS OF TASKS CONSIDERED NECESSARY FOR PERFORMING ORDINARY AND EMERGENCY RESPONSE SHIPBOARD FUNCTIONS
Shipboard Tasks, Function,
Event, or Condition

Related Physical Ability

Acceptable Demonstration

Routine movement on slippery, uneven, and
unstable surfaces

Maintain balance (equilibrium)

Has no disturbance in sense of balance

Routine access between levels

Climb up and down vertical ladders and stairways

Is able, without assistance, to climb up and down vertical ladders and
stairways

Routine movement between spaces and
compartments

Step over high doorsills and coamings, and move
through restricted accesses

Is able, without assistance, to step over a doorsill or coaming of 24 inches
(61 centimeters) in height. Able to move through a restricted opening of 24
inches

Open and close watertight doors, hand cranking
systems, open/close valve

Manipulate mechanical devices using manual and
digital dexterity, and strength

Is able, without assistance, to open and close watertight doors that may
weigh up to 55 pounds (25 kilograms); should be able to move hands/arms
to open and close valve wheels in vertical and horizontal directions; rotate
wrists to turn handles; able to reach above shoulder height

Handle ship's stores

Lift, pull, push, carry a load

Is able, without assistance, to lift at least a 40 pound (18.1 kilogram) load
off the ground, and to carry, push, or pull the same load

General vessel maintenance

Crouch (lowering height by bending knees); kneel
(placing knees on ground); stoop (lowering height by
bending at the waist); use hand tools such as
spanners, valve wrenches, hammers, screwdrivers,
pliers

Is able, without assistance, to grasp, lift, and manipulate various common
shipboard tools

Emergency response procedures including
escape from smoke-filled spaces

Crawl (ability to move body using hands and knees);
feel (ability to handle or touch to examine or
determine differences in texture and temperature)

Is able, without assistance, to crouch, kneel, and crawl, and to distinguish
differences in texture and temperature by feel

Stand a routine watch

Stand a routine watch

Is able, without assistance, to intermittently stand on feet for up to four
hours with minimal rest periods

React to visual alarms and instructions,
emergency response procedures

Distinguish an object or shape at a certain distance

Fulfills the eyesight standards for the merchant mariner credential applied
for (see the NMC website for more info; http://www.uscg.mil/nmc/medical.asp)

React to audible alarms and instructions,
emergency response procedures

Hear a specified decibel (dB) sound at a specified
frequency

Fulfills the hearing standards for the merchant mariner credential applied
for

Make verbal reports or call attention to
suspicious or emergency conditions

Describe immediate surroundings and activities, and
pronounce words clearly

Is capable of normal conversation

Participate in firefighting activities

Be able to carry and handle fire hoses and fire
extinguishers

Is able, without assistance, to pull an uncharged 1.5 inch diameter, 50' fire
hose with nozzle to full extension, and to life a charged 1.5 inch diameter
fire hose to firefighting position

Abandon ship

Use survival equipment

Has the agility, strength, and range of motion to put on a personal
floatation device and exposure suit without assistance from another
individual

Demonstration of Physical Ability Results

COMMENTS:

Applicant has physical strength, agility, and flexibility to
perform all of the items listed above
Applicant does NOT have physical strength, agility, and
flexibility to perform any one of the items listed above

Applicant Name:
(First Name, MI, Last Name)

Date of Birth:
(mm/dd/yyyy)
Previous Edition Obsolete

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Section IX: Food Handler Certification
If applicable, to be completed by the Medical Practitioner if Food Handler Certificate is sought by the applicant.
Yes

Applicant is free from communicable disease.

No

Section X: Summary
Applicant proof of identity verified:

Yes

Overall fitness recommendation:

Competent

No
Not Competent

Needs Further Review

Supporting medical testing and documentation for medical conditions included with submission:

Yes

No

Comments:

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

(M. I.)

(Last Name)

Signature

License Number

Date

(mm/dd/yyyy)

Designated Medical Examiner (DME) number (if applicable)
(

Phone Number

Office Address
City

Applicant Name:
(First Name, MI, Last Name)

)

State

-

(000) 000-0000

Zip Code

Date of Birth:
(mm/dd/yyyy)
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Merchant Mariner Medical Certificate
Evaluation Report Instructions
· Detailed guidance on the medical and physical evaluation guidelines for merchant mariner credentials can be viewed at the National Maritime Center website
(http://www.uscg.mil/nmc/medical.asp).
· Additional information can also be obtained from NMC at: Commanding Officer, National Maritime Center,100 Forbes Drive, Martinsburg, WV 25404 or 1-888-IASKNMC
(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 and submit it to the U.S. Coast Guard. Applicants seeking a raise-ingrade are required to submit this form if a previous medical evaluation has not been submitted within the last 3 years. Guidance for required submission of this form can be
found at the National Maritime Center website (http://www.uscg.mil/nmc/medical.asp).
Instructions for Applicants
Applicants are required to complete the Applicant Information in Section I, Medications in Section III, and 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.
General Instructions for Medical Practitioner
1. The Coast Guard requires a physical examination and certification to 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 medical practitioner who performed the examination
must verify Sections III and IV, and complete Sections V, VI, VII, VIII, IX, and X of this form.
4. 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.
5. Applicants must report their relevant medical conditions to the best of their knowledge, and the medical practitioner must verify the medical conditions. Check "YES" if the
applicant has had a previous diagnosis or treatment of the condition by a health care 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 medical practitioner, or any other health care provider to the satisfaction of the 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 medical practitioner must address all reported conditions 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, the treatment, and any additional information as appropriate,
referring to the evaluation data listed at the National Maritime Center website (http://www.uscg.mil/nmc/medical.asp).
Additional sheets may be added by the applicant and/or the medical practitioner if needed to complete this section of the form. (Include applicant's name and DOB on
each additional sheet.)
Supporting medical documentation and testing for all identified conditions potentially requiring further review should be submitted with each application as per the
guidelines found on the NMC website (http://www.uscg.mil/nmc/medical.asp).
Detailed guidelines on medical conditions subject to further review can be found on the NMC website. Medical practitioners should be familiar with the guidelines
contained within this document. Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials can be downloaded from the NMC website
(http://www.uscg.mil/nmc/medical.asp) or by calling the NMC at 1-888-IASKNMC (1-888-427-5662).
6. 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.
7. The medical practitioner is not required to perform or witness every examination, test, or demonstration. These may be referred to other qualified practitioners such as
audiologists or optometrists; however, they must be reviewed to the satisfaction of the medical practitioner. Page 6 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 to the satisfaction of the
medical practitioner. The 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 medical practitioner is true and correct to the best of his/her knowledge and that the medical practitioner has not
knowingly omitted or falsified any material information relevant to this form.
8. If the medical practitioner is unable to determine the applicant's physical ability, the applicant should be referred to another health care provider who can properly evaluate
and test physical abilities.

Applicant Name:
(First Name, MI, Last Name)

Date of Birth:
(mm/dd/yyyy)
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9. The medical practitioner shall complete Section IX for all applicants requiring Food Handler Certification. The medical practitioner need not perform any additional
laboratory testing unless it is deemed clinically necessary. Applicants and currently employed food workers should report information about their health as it relates to
diseases that are transmissable through food. The following issues should be considered by the medical practitioner when certifying an applicant:
a. The applicant reports they have been diagnosed with an illness due to organisms such as Salmonella Typhi, Shigella spp., Shiga-toxin-producing Escherichia coli,
Hepatitis A virus, etc.
b. The applicant reports they have at least one symptom caused by illness, infection, or other source that is associated with an acute gastrointestinal illness such as
diarrhea, fever, vomiting, jaundice, or sore throat with fever.
c. The applicant reports they have a lesion containing pus, such as a boil or infected wound, which is open or draining and is on hands or wrists or on exposed portions of
the arms.
d. The applicant reports they have had Salmonella Typhi within the past three months, Shigella spp. within the past month, Shiga toxin producing Escherichia coli within
the past month, or Hepatitis A virus ever.
e. The applicant reports they are suspected of causing or being exposed to a confirmed disease outbreak caused by organisms such as Salmonella Typhi, Shigella spp.,
Shiga-toxin-producing Escherichia coli, Hepatitis A virus, etc. This would include outbreaks associated with events such as a family meal, church supper, or festival
because the food employee ate food implicated in the outbreak, or ate food at the event prepared by a person who is infected or who is suspected of being a shedder of
the infectious agent.
f. The applicant reports they live in the same household as, and have knowledge about, a person who is diagnosed with organisms such as Salmonella Typhi,
Shigella spp., Shiga-toxin-producing Escherichia coli, Hepatitis A virus, etc.
g. The applicant reports they live in the same household as, and have knowledge about, a person who attends or works in a setting where there is a confirmed disease
outbreak caused by organisms such as Salmonella Typhi, Shigella spp., Shiga-toxin-producing Escherichia coli, Hepatitis A virus, etc.
10. Instructions for providing proof of identity
a. Applicants shall present acceptable proof of identity to the medical practitioner conducting examinations.
b. Medical practitioners must verify the identity of applicants before conducting examinations.
c. Proof of identity shall consist of one current form of valid government issued photo identification.
d. 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.

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 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 18 minutes. You may submit any comment concerning the accuracy of this burden estimate or any
suggestions for reducing the burden to the National Maritime Center, 100 Forbes Drive, Martinsburg, WV 25404.

Applicant Name:
(First Name, MI, Last Name)

Date of Birth:
(mm/dd/yyyy)
Previous Edition Obsolete