CG-719K/E Application for Medical Certificate, Short Form

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1625-0040

U.S. Coast Guard

Exp. Date: 03/31/2021

APPLICATION FOR MEDICAL CERTIFICATE, SHORT FORM (FORM CG-719K/E)

------ Instructions -----Who must submit this form?
1. Mariners applying for, or holding a Merchant Mariner Credential (MMC) with only an entry-level national endorsement or a staff officer national endorsement
who want to serve as Food Handler may use this form. (Please include the instruction page in addition to sections I, II, V and VI of this form.)
2. Mariners applying for or holding an MMC with only an entry-level endorsement or a staff officer endorsement who require a medical certificate that complies
with the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW) or, Maritime Labour Convention (MLC)
requirements and will not stand navigational or engineering watches may apply using this form. No lookout duties will be authorized.
3. All other applicants for a Medical Certificate must use the Application for Medical Certificate, Form CG-719K.

Who may conduct this exam?
All exams, tests and demonstrations must be performed, witnessed or reviewed by a physician, physician assistant, or nurse practitioner licensed by a state in
the U.S., a U.S. possession, or a U.S. territory.

Section I: Applicant Information - To be completed by the Applicant and reviewed by the Medical Practitioner (MP)
• Legal Name - Enter complete legal name.
• Reference Number - If you have been credentialed by the Coast Guard in the past, enter your reference number.
• Date of Birth - If applicant is under 18 years of age, attach a notarized statement, signed by a parent or guardian, authorizing the Coast Guard to issue a
Medical Certificate.
• Gender - Enter your gender.
• Home Address - Principle place of residence. PO Box is not acceptable.
• Delivery/Mailing Address - The address to which you want all correspondence and issued certificates sent. If blank, correspondence and credentials will be
sent to the Home Address.
• Primary Phone Number - Provide a primary phone number.
• Alternate Phone Number - Provide an alternate phone number (optional).
• E-mail Address (optional) - If provided, the National Maritime Center (NMC) may attempt to contact you via e-mail. You will receive automated updates
regarding the status of your application.
• Other - Please provide additional means of communicating with you (satellite phone, work phone, etc.) (optional).

Section II: Food Handler Certification - To be completed by the Medical Practitioner
Refer to instructions provided in this section. The Medical Practitioner should initial and date at the bottom of each page of the application, where indicated.

Section III: Physical Information - To be completed by the Medical Practitioner
The Medical Practitioner must document the results of the physical information in this section. The Medical Practitioner should initial and date at the bottom
of each page of the application, where indicated.

Section IV: Demonstration of Physical Ability - To be completed by the Medical Practitioner
Applicants must provide a demonstration of physical ability as described in the table and instructions in this section. The Medical Practitioner should initial and
date at the bottom of each page of the application, where indicated.

Section V: Summary - To be completed by the Medical Practitioner
a. Applicant Proof of Identity Provided - Applicants shall present acceptable proof of identity to the Medical Practitioner conducting examinations. Proof of
identity shall consist of one current form of valid government-issued photo identification. Examples of acceptable proof of identity include 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, Merchant Mariner Credential, or Transportation Worker Identification Credential (TWIC).
b. Certification Recommendation - The Medical Practitioner should provide their recommendation and overall opinion of the mariner's fitness.
c. Assessment - For STCW/MLC compliant medical certificate.
d. Discussion - The Medical Practitioner should discuss any conditions or issues of concern.
e. Medical Practitioner (Attestation and Information) - The Medical Practitioner must sign and date the attestation where indicated.

Section VI: Applicant Certification - To be completed by the Applicant
Applicant certifies that the information provided is true and correct.

Section VII: Applicant Consent (optional) - To be completed by the Applicant
Third Party Authorization - If you want the NMC to be able to discuss, release, or receive information/documents regarding your medical certificate application
with a third party (spouse, employer, school, union, etc.) you must provide specific guidance to the NMC regarding what issues we may discuss and with whom.
You may allow release of all information to certain individuals or entities. If you limit the release of certain information you must be specific by making a selection
on the application or by attaching additional documentation. For each selection made, ensure the Name of the Organization or Third Party, Organization Point of
Contact (if applicable), Address and Phone Number is completed. If you wish to provide multiple Third Party Authorizations, attach additional pages as needed. A
sample may be found on the NMC website: https://www.uscg.mil/nmc/credentials/forms/3rd_party_authorization_med_cert.pdf. Please sign and date for
each type of consent that you wish to authorize.
a. Consent for Medical Practitioner to Release Information to the Coast Guard
b. Consent for Coast Guard to Release Information to a Third Party
c. Consent for Third Party to Act on your Behalf

MEDICAL PRACTITIONER INITIALS:

Print Applicant Name:(Last, First, MI.)
CG-719K/E (04/17)

DATE:

Date of Birth: (MM/DD/YYYY)
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DEPARTMENT OF HOMELAND SECURITY

OMB No. 1625-0040

U.S. Coast Guard

Exp. Date: 03/31/2021

APPLICATION FOR MEDICAL CERTIFICATE, SHORT FORM (FORM CG-719K/E)
Section I: Applicant Information - To be completed by the Applicant and reviewed by the Medical Practitioner
Last Name

First Name

Reference Number (if applicable)

Gender:

Middle Name

Suffix (Jr., Sr., III)

Date of Birth (MM/DD/YYYY)
Male

Female

Please indicate best method(s) of contact by checking the appropriate box(es).
Home Address (PO Box NOT acceptable)
Primary Phone Number

Street Address

City

State

Zip Code

Alternate Phone Number

Delivery/Mailing Address, if different (PO Box acceptable)

E-mail Address

City

Other

State

Zip Code

Section II: Food Handler Certification - To be completed by the Medical Practitioner
1.

Food Handlers must obtain a statement from the Medical Practitioner that attests that they are free of communicable diseases that pose a direct threat to
the health or safety of other individuals in the workplace. For applicants who have requested Food Handler Certification (Food Handler box is checked in
Section I, above), the Medical Practitioner may provide the attestation by answering Yes or No to the question in bold below.

2. Communicable disease is defined in 46 CFR 10.107 as any disease capable of being transmitted from one person to another directly, by contact with
excreta or other discharges from the body; or indirectly, via substances or inanimate objects contaminated with excreta or other discharges from an infected
person.
3. The Medical Practitioner need not perform any additional 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. Circumstances that the Medical Practitioner should
consider when certifying an applicant include, but are not limited to, the following:
a. Whether the applicant reports they have been diagnosed with, or exposed to an illness due to organisms including, but not limited to, Salmonella Typhi,
Shigella Spp., Shiga-toxin-producing Escherichia coli, or Hepatitis A virus within the past month.
b. Whether 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. Whether 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.

Is the applicant free from communicable disease?

Yes

No

N/A

Section III: Physical Information - To be completed by the Medical Practitioner
Height (Inches Only)

Weight (lbs)

Distinguishing Marks: (Please Print)

MEDICAL PRACTITIONER INITIALS:
CG-719K/E (04/17)

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

Date of Birth: (MM/DD/YYYY)

Section IV: Demonstration of Physical Ability - To be completed by the Medical Practitioner
LISTS OF TASKS CONSIDERED NECESSARY FOR PERFORMING ORDINARY AND EMERGENCY RESPONSE SHIPBOARD FUNCTIONS
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 (600 millimeters) in height. Able to
move through a restricted opening of 24 x 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
kilograms) 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

Distinguish an object or shape at a certain distance

React to audible alarms and
instructions, emergency response
procedures

React to audible alarms and instructions, emergency
response procedures

React to audible alarms and instructions, emergency
response procedures

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
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

Title 46 of the Code of Federal Regulations (CFR) requires that ratings, including entry level, and food handler serving on vessels to which STCW applies
must provide a demonstration of physical ability. The table above lists activities that the applicant must 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). Medical and Physical
Evaluation Guidelines for Merchant Mariner Credentials can be downloaded from https://www.uscg.mil/hq/cg5/nvic/pdf/2008/NVIC_04-08.pdf or
by calling the NMC at 1-888-IASKNMC (1-888-427-5662).
Physical Ability
Results:

Applicant has the physical strength, agility, and flexibility to
perform all of the items listed in the physical ability table.

Applicant does NOT have the physical strength, agility, and flexibility
to perform all of the items listed in the physical ability table.

COMMENTS:
(Please Print)

MEDICAL PRACTITIONER INITIALS:
CG-719K/E (04/17)

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DATE:
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Print Applicant Name:(Last, First, MI.)

Date of Birth: (MM/DD/YYYY)

Section V: Summary - To be completed by the Medical Practitioner
a. Applicant proof of identity provided:

Yes

No b. Certification recommendation:

Recommended

Not Recommended

Needs Further Review

c. Assessment: (for STCW/MLC compliant medical certificate) To the best of my knowledge, mariner is free from any medical condition likely
to be aggravated by service at sea or to render the seafarer unfit for such service or to endanger the
Yes
No
Needs Further Evaluation
health of other persons on board.
d. Discussion: Please discuss any concerns. Please print or type.

e. 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.
Last Name

First Name

Signature

M.I.

Date (MM/DD/YYYY)

License Number

State

Phone Number
MD

DO

PA

NP

Office Street Address

City

State

Zip Code
(Place office address stamp here)

Section VI: Applicant Certification - To be completed by the Applicant
My signature below attests, subject to prosecution under 18 USC § 1001, that all information provided by me on this 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 Notice that accompanies this form.
Signature of Applicant

Date (MM/DD/YYYY)

PRIVACY NOTICE
Authority: 14 U.S.C. 632; 46 U.S.C. 2103, 7101, 7302, 7502, 46 C.F.R. 10.301
Purpose: The information is collected by the Coast Guard to determine whether an applicant meets the regulatory standards for issuance of a U.S. Merchant
Mariner Credential (MMC). The Coast Guard evaluates an applicant's qualifications to determine compliance with the national and international requirements for
issuance of the MMC, any endorsement within the MMC, and medical certificate.
Routine Uses: The information is used by authorized Coast Guard personnel who have a need for the record to determine whether an applicant is a safe and
suitable person and qualifies for the MMC, any endorsement within the MMC, and medical certificate. In addition, the Coast Guard uses this information to
maintain and update records of merchant mariner documentation transactions. The information will not be shared outside of DHS except in accordance with the
provisions of DHS/USCG-030 Merchant Seamen's Records System of Records, 74 FR 30308 (June 25, 2009).
Disclosure: Furnishing this information (including your SSN) is voluntary; however, failure to furnish the requested information may result in the non-issuance
of the MMC, any endorsement within the MMC, and medical certificate.
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 this form is 10 minutes. You may submit any comments concerning the accuracy of this
burden or any suggestions for reducing the burden to the Chief, Office of Merchant Mariner Credentialing, 2703 Martin Luther King, Jr. Ave, S.E., STOP 7509,
Washington, D.C., 20593-7509.
CG-719K/E (04/17)

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

Date of Birth: (MM/DD/YYYY)

Section VII: (Optional) Applicant Consent - To be completed by the Applicant

Declined

a. CONSENT FOR MEDICAL PRACTITIONER TO RELEASE INFORMATION TO THE COAST GUARD:
My signature below authorizes the Medical Practitioner, who has signed the certification on page 4 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 merchant mariner medical certificate.
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 merchant mariner medical certificate. This authorization will remain in effect until the Coast
Guard determines whether to issue me the requested merchant mariner medical certificate for maritime service, but no longer than one year.
I have read and understand the following statement about my rights:
u

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.

u

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

u

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

Signature of Applicant

Date (MM/DD/YYYY)

b. CONSENT FOR COAST GUARD TO RELEASE INFORMATION TO A THIRD PARTY:
My signature authorizes the Coast Guard to share my medical information with the third party indicated below. I understand that I may revoke this
authorization at any time prior to its expiration date by notifying the Coast Guard in writing.
Please provide the Name of the Organization or Third Party, Address, and Phone Number. Additional Third Party Authorization information may be
attached separately.
Name of Organization or Third Party

Organization Point of Contact (if applicable)

Phone Number

Street Address

City

State

Signature of Applicant

Zip Code

Date (MM/DD/YYYY)

c. CONSENT FOR THIRD PARTY TO ACT ON MY BEHALF:
My signature authorizes the following third party to act on my behalf in all matters pertaining to the processing of my current application for a medical
certificate. This means that the Coast Guard will share my medical information and correspond with the third party, and it means that the third party can
request agency action on my behalf, and receive my medical certificate.
Please provide the Name of the Organization or Third Party, Address, and Phone Number. Additional Third Party Authorization information may be
attached separately.
Name of Organization or Third Party

Organization Point of Contact (if applicable)

Phone Number

Street Address

City

State

Signature of Applicant

CG-719K/E (04/17)

Zip Code

Date (MM/DD/YYYY)

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