CG-719K/E Merchant Mariner Evaluation of Fitness for entry Level R

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

Merchant Mariner Evaluation of Fitness for
Entry Level Ratings

OMB 1625-0040

Section I – Applicant Information
Name (Last, First, Middle) of Applicant:

Social Security Number:

Age:

Gender:

Date of Birth
(MM/DD/YYYY):

Section II – Physical Information
Height:

Eye Color:

Distinguishing Marks:

Weight:

Hair Color:

Body Mass Index:

Section III – Physical Ability Certification
An applicant for an Entry Level Rating [ordinary seaman, wiper, or steward’s department (food handler)] is not
required to complete a physical examination, but they must have the agility, strength, and flexibility to complete
the following shipboard tasks and related physical abilities as described in the table below:
Shipboard Tasks, function, event
or condition:

Related Physical Ability:

The examiner should be satisfied that the applicant:

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. Reach above shoulder
height.

Handle ship’s stores.

Lift, pull, push and 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);
and 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 (the ability to move the body with
hands and knees); feel (the ability to
handle or touch to examine or determine
differences in texture and temperature).

Is able, without assistance, to crouch, keel 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(s)
applied for. See footnote 1 of this table & enclosure (5) of NVIC 408.

React to audible alarms and
instructions, emergency response
procedures.

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

Fulfills the hearing capacity standards for the merchant mariner
credential(s) 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 lift a charged 1.5
inch diameter fire hose to fire fighting position.

Abandon ship.

Use survival equipment.

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

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Place an X in the appropriate block below.
Applicant has the physical strength, agility, and
flexibility to perform all of the items listed above.
Comments:

Considering the above requirements and noting the duties to be
performed by the applicant aboard a vessel of the United States, I
consider the applicant (Please check one)

Name of Physician/Physician’s Assistant/Nurse Practitioner:

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

Competent

Not
Competent

Needing
Further Review

Office Address, City, State, Zip Code:

Telephone Number:

License Number:
National Provider Number:

Signature of Physician/Physician’s Assistant/Nurse Practitioner

Date

Section IV – Applicants Signature
I certify that all information provided by me is complete and true to the best of my
knowledge

X

Date

________________________________________
Signature of Applicant

Description of the requirements for Certificate of Fitness
Title 46 of the Code of Federal Regulations (CFR) requires that an applicant for Entry Level Ratings valid for service on a seagoing
vessel of 200 or more gross register tons (GRT) (domestic tonnage) “Provide a document issued by a qualified medical practitioner
attesting to the applicant’s medical fitness to perform the functions for which the document is issued”. The following is a list of activities
the Applicant shall be physically able to perform:
For a vessel to be operated safely, it is essential that the crewmembers be physically fit and free of debilitating illness and injury. The
seafaring life is arduous, often hazardous, and the availability of medical assistance or treatment is generally minimal. As the
international trend toward smaller crews continues, the ability of each crewmember to perform his or her routine duties and respond to
emergencies becomes even more critical.
All mariners should be capable of living and working in cramped spaces, frequently in adverse weather causing violent evolutions such
as fire-fighting or launching lifeboats or life rafts. Members of the deck and engine department must be capable of physical labor,
climbing and handling moderate weights (from 30-60 pounds).
Detailed guidance on the medical and physical evaluation guidelines for merchant mariner credentials is contained in Navigation 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, 1-888-I-ASK-NMC (1-888-427-5662)
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.
U.S. Dept. of Homeland Security, USCG. CG-719K/E, Rev. 01-09
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