CG-719K/E Merchant Mariner Evaluation of Fitness For Entry Level R

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1625-0040

U.S. Coast Guard
Exp. Date: 06/30/2012
MERCHANT MARINER EVALUATION OF FITNESS FOR ENTRY LEVEL RATINGS
Section I – Applicant Information and Signature
Name: Last

Age:

First

Gender:

Middle

Reference Number: (If applicable)

Social Security Number (000-00-0000): Date of Birth (MM/DD/YYYY):

Applicant Signature: I certify that all information provided by me is complete and
true to the best of my knowledge.

X

Date: (MM/DD/YYYY)

Section II – Physical Information (Sections II-IV should be completed by the Medical Practitioner)
Height (Inches Only):

Weight (lbs):

Body Mass Index (BMI):

Distinguishing Marks:

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 shipboard tasks and related physical abilities as described
in the table on the following page.
Place an X in the appropriate block below:
Applicant has physical strength, agility, and flexibility to perform
all of the items described in the table on the following page.

Applicant does NOT have physical strength, agility, and flexibility
to perform any one of the items described in the table on the
following page.

COMMENTS:

Section IV – Food Handler Certification - If applicable, to be completed by the Medical Practitioner if Food Handler Certificate is sought by the Applicant.
Applicant is free from communicable disease.

Yes

No

Medical Practitioner Contact Information
Last

First

Middle

Name
Signature: I certify that all information provided by me is
complete and true to the best of my knowledge.
Address

City

State

Zip Code

X _______________________________________
MD/DO

Telephone:

CG-719K/E (07/12)

License Number:

Designated Medical Examiner Number
(DME):

PA

NP

Date (MM/DD/YYYY):

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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 firefighting 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) 0408. Additional information is also available at the National Maritime Center (NMC) website at: 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, 1-888-IASKNMC (1-888-427-5662).

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 enclosure (5) of NVIC 4-08

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 fire fighting 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 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

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 transmissible through food. The following issues should be considered by the medical practitioner when certifying an applicant:
1. 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.
2. 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.
3. 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.
4. 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.
5. 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 the 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.
6. 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.
7. 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.

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 a Federal agency casualty investigators.
c. The 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 National
Maritime Center, 100 Forbes Drive, Martinsburg, WV 25404.

CG-719K/E (07/12)

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