Manual Seafarer Medical Examinations

Netherlands Shipping Inspectorate

2018

0
Contents

1 Introduction 2

2 Medical examinations of seafarers 3

2.1 Areas of concern 3

2.2 Duty categories 5

2.3 Vision standards 6

2.4 Hearing standards 8

2.5 Fitness criteria 9

2.6 Filling out the Seafarer Medical Certificate 10

3 Medical examiners’ appointment and recognition 11

4 Additional information 12

4.1 Registering results 12

4.2 Surveillance 12

4.3 Ordering certificates 12

5 Rules and regulations 13

5.1 Keuringsreglement voor de Zeevaart 2012 13

5.2 ILO/IMO guidelines; appendix A - E 19

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1 Introduction
Medical examinations for Dutch Flag personnel may only be performed by doctors who have been
appointed or recognized by The Netherlands’ Administration. Applicable rules and procedures are
embedded in Dutch Law. This NSI (Netherlands Shipping Inspectorate) manual is to be used by all
appointed and recognized doctors abroad and replaces all previous issues.

The examining doctor shall assess whether the candidate meets applicable medical standards and
whether he or she is capable to perform their duty on board ship. Next to the seafarer’s own fitness
for duty, secondary safety of fellow crew members and other mariners should be taken into
consideration. In order to judge any safety risks, the examining doctor should be well aware of the
working conditions on board ship.

This manual addresses seafarers’ examinations, procedures of appointment and recognition of

examining doctors and practical matters such as ordering certificates and registration of issued
Seafarer Medical Certificates (SMC) or Declarations of Medical Unfitness.
Any additional instructions issued by the NSI’s Medical Adviser should be executed, as they are to
be considered mandatory as written in article 3, first note, of the Netherlands’ “Keuringsreglement
voor de zeevaart 2012”.

Issuing SMC’s to the obese (page 7) will be addressed more specifically. NSI will continue to focus
on surveillance and enforcement concerning this topic in 2018.

In case of any uncertainties or the need of clarification, please consult the NSI Medical Adviser via
[email protected] .

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2 Medical examinations of seafarers

2.1 Areas of concern

Medical examination requirements
The official text of the examination procedure, the examination directions and the medical
requirements can be found in the Ministerial Decree "Medical Examinations of seafarers 2012" .
The medical standards within this Decree are a copy of annex A – E of the ILO/IMO Guidelines on
the medical examination of seafarers . Annex A and B include the hearing and vision standards.
Annex C covers the physical capability requirements and annex D the fitness criteria for medication
use. Annex E describes the fitness criteria for common medical conditions.

Duty categories
Four groups are being discerned:
Seafarers with look-out or watch duties on the bridge.
Seafarers with look-out or watch duties in the engine room.
Seafarers without look-out or watch duties, but with safety or security duties.
Seafarers without any duties mentioned above.

All crew members who execute look-out or watch duties on deck and bridge or in the engine room
must comply with hearing and vision standards of annex A and B of the ILO/IMO-guidelines, which
are derived from the “International Convention on Standards of Training, Certification and
Watchkeeping for Seafarers “ (STCW). The hearing and vision standards of the seafarers who do
not need to comply with STCW, group four without safety duties, are mentioned in annex 2 of the
Ministerial Decree "Medical Examinations of seafarers 2012. All four groups have to comply with
the Maritime Labour Convention (MLC). This means that the first three categories have to comply
with both the STCW and the MLC standards, group four solely with the MLC standards.

Verification prior to medical examinations

Prior to medical examination the identity of the candidate should always be verified and a
previously issued SMC and/or exemption/dispensation or rejection should be presented by the
examinee.

Contents medical examination

Case history and family history
A general physical examination
A general assessment of the mental state
Test for tuberculosis if indicated
Urine tests
Additional tests of the blood or feces if indicated
Examination of the visual system
Examination of the auditory system
On indication, request additional examinations by a specialist.

Anamnesis, physical examination and assessment of the seafarers’ mental state may
solely be performed by the appointed or recognized doctor and is therefore not to be
passed on to non-appointed staff. This also counts for the issuing and signing of medical
certificates.

Physical strength
During the examination of seafarers with look-out or watch duties one should not only assess
fitness for duty under standard conditions, but consider demanding situations at sea, such as
emergencies, climate changes and severe weather conditions. Also consider they will likely attend
STCW-trainings. Failing a required STCW-training will restrict the seafarer’s duties.
Example: https://www.youtube.com/watch?v=6hYPunKG-qk

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Testing for tuberculosis
A chest X-ray, IGRA-test or Mantoux-test is part of the examination, if the seafarer originates from,
or is employed in a tuberculosis risk area, and/or is so indicated for medical reasons. At the time of
the examination, the test for tuberculosis may be not older than 1 month (see 2.5 on page 9).

Visual acuity in youth

It is of importance to note that visual acuity in youth may still develop until the age of 25 is
reached. An 18 year old youth hardly meeting standards, may well fail by the time he/she is 25
years old. The examining doctor should point out this risk to such examinee.

Students
It is not mandatory for freshmen to have had an examination before starting their education. Not
until the student’s first journey out to sea a SMC is mandatory. In order to prevent harsh situations
in which an unprepared student is declared unfit for duty halfway his/her education, NSI advises
colleges and doctors to promote voluntary examinations before going to college.

Fit for duty

Only examinees that meet appropriate standards may be declared fit for duty. The appointed
doctor may order restrictions on the SMC. When in doubt, the medical adviser may be consulted.
Unruly declaration of fitness may result in serious problems for examinee, emloyers, insurance
companies and the examining doctor.

Period of validity
Two years, unless a restriction in time is indicated.
Youth under 18 are always restricted to a period of one year or less.

Unfitness
Any examinee not meeting standards and not holding a valid exemption, must be decalerd unfit for
duty. The examinee is handed a Declaration Of Medical Unfitness and is explained his/her
right to an examination by a referee.

Re-examination by referee
Any examinee (outside The Netherlands) who wishes to apply for a re-examination by referee, may
be directed to NSI’s medical adviser for further instructions.

Exemptions
NSI’s medical adviser may issue exemption for individual cases. Questions on the issuing or reneal
of such exemptions may be addressed at [email protected]

Non-Dutch crew on non-Dutch Flag ships

Several countries have recognized The Netherlands Seafarer Medical Certificate to be valid for their
own flag. NSI does not object to issuing Dutch certificates for foreign flag crew if requested so.

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2.2 Duty categories

FUNCTIECATEGORIE DUTIES ON BOARD

Zeevarende met uitkijk- of wachtfunctie op de Seafarer with look-out or watch duties on bridge
brug
Kapitein / gezagvoerder Master / Captain
Loods Pilot
Eerste stuurman Chief Mate, First Mate, Chief Officer
Stuurman Mate, Deck Officer
MO / Maritiem officier MO / Maritime Officer
Officier Deck Officer
Stuurman-WTK beperkt werkgebied (SMBW) Mate Engineer near coastal voyages (NCV)
Gezel dekdienst Rating deck (with look-out duties)
Schipper (visserij) Skipper (fishery)
SWTK / Stuurman-werktuigkundige (vis) Mate-engineer (fishery)
Bootsman Bosun / Boatswain
Matroos Able Bodied Seaman (A/B)
Cadet Cadet
Kwartiermeester Deckhand
Geïntegreerd scheepsgezel / scheepstechnicus Rating deck-engine room
Pompman Pump man
Onderofficier Petty Officer
Stagiaire maritiem officier Trainee Maritime Officer
Student, leerling nog op school Student / Trainee / Deck Cadet
Zeevarende met wachtfunctie in de machinekamer Seafarer with watch duties in the engine room
Hoofdwerktuigkundige (HWTK) / Hoofdmachinist Chief Engineer
WTK / Werktuigkundige Engineer Officer / Officer of the watch (OOW)
Elektrotechnisch officier (ETO) Electrotechnical Officer (ETO)
Elektrotechnisch gezel Electrotechnical Rating (ETR)
Machinist Officer with watch duties in the engine room
Gezel machinekamer Rating engine room
Motorman, motordrijver Motorman
Assistent WTK Assistant Engineer Officer
Student, leerling nog op school Engineroom Cadet
Zeevarende zonder uitkijk- of wachtfunctie maar Seafarer without look-out or watch duties, but
met veiligheids- of beveiligingstaken with safety and / or security duties
Kok / assistent kok Cook / Assistant cook
Arts Physician / Doctor
Radio officier Radio Officer
Gezel Rating / Ordinary Sailor (O/S)
Elektricien Electrician
Pijpenman / Olieman / Lasser / Monteur Fitter / Wiper / Welder / Mechanic
Officier hoteldienst Hotel manager
Bediende / Steward Steward / Purser
Veiligheidsofficier Safety Officer
Medic Medic
Pompman Pump man
Hofmeester Stewardess / Receptionist
Zeevarende zonder bovengenoemde functies Seafarer without above mentioned duties
Kok / assistent kok Cook / Assistant cook
Arts Physician / Doctor
Etc.

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2.3 Vision standards
Vision
Demands under STCW are written in table A-I/9 of this convention. This table is part of appendix A
of the ILO/IMO guidelines on the medical examination of seaferers (annex 6.2).

Category Minimal demands

Lookout or watchkeeping on the bridge Each individual eye, either with glasses or lenses
0.5, uncorrected 0.1

Lookout or watchkeeping in the engine room Each individual eye, either with glasses or lenses
0.4, uncorrected 0.1

No lookout or watchkeeping, but with Each individual eye uncorrected 0.1

safety- or security tasks
Seafarers without any of the above duties Both eyes simultaneously, either with glasses or
lenses 0.1

Colour vision

Demands under STCW are written in table A-I/9 of this convention. This table is part of appendix A
of the ILO/IMO guidelines on the medical examination of seaferers (annex 6.3).

Seafarerers with lookout or watchduties on the bridge must comply with “CIE colour vision
standard 1 or 2” , while seafarerers with lookout or watch duties in the engine room must comply
with “CIE colour vision standard 1, 2 or 3”.
CIE is the “Commission Internationale de l’Eclairage”. This internationally acclaimed committee
has set standards on colour vision for seafarers n 2001, which have been adopted by STCW
(Standards of Training, Certification & Watchkeeping).

Seafarerers with lookout or watch duties on the bridge

The initial test for colour vision is Ishihara’s test. A score of 0, 1 or 2 mistakes complies with
standard 1. If in doubt, the standard advises an equivalent test, such as Hardy, Rand and Rittler
(HRR). Mild defect = pass, medium or strong defect = fail. Three or more mistakes in Ishihara’s,
but 0 mistakes in the Lantern test, complies with standard 1 also. 1 or 2 mistakes in Lantern test
complies with standard 2.

 0, 1 or 2 mistakes in Ishihara = pass

 3 mistakes or more in Ishihara -> HRR test: mild = pass, medium or strong = fail
 Lantern test: 0, 1 or 2 mistakes = pass, 3 or more mistakes = fail

Seafarerers with lookout or watch duties in the engine room

Compliance with standards 1 or 2 = pass. If failed for either of these, but tested for no more than
one crossing in Farnsworth’s D15 test = pass.

 Equal to seafarers with look-out and watch duties on the bridge

 Additional option in D15 test: 0 to 1 crossings = pass, over 1 crossing = fail.

Seafarers without lookout or watch duties, but with safety or security tasks (category 3)
or all other personnel (category 4)
No colour vision requirements.

Colour vision must be tested every six years.

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2.4 Hearing standards
Demands under STCW are written in appendix B of the ILO/IMO guidelines on the medical
examination of seaferers.

STCW (categories 1, 2 and 3, with security tasks)

Hearing capacity for seafarers apart from those identified below should be an average of
at least 30 dB (unaided) in the better ear and an average of 40 dB (unaided) in the lesser
ear within the frequencies 500, 1,000, 2,000 and 3,000 Hz (approximately equivalent
to speech-hearing distances of 3 metres and 2 metres, respectively).
It is recommended that hearing examinations should be made by a pure tone audiometer.

Category 4 (no security tasks)

1. A test with the tone audiometer is performed once every 2 years. A hearing loss of an average
of 40 dB (HL) for the best performing ear is a reason for unfitness. A hearing loss of an average of
40 dB (HL) or more for the worst ear is a reason for unfitness. The applicable norm is the
arithmetic mean of the unmasked conducting thresholds at 500, 1000, 2000 and 3000 Hz. If the
equipment does not allow for measurement at 3000 Hz, the threshold at 3000 Hz per ear may be
calculated on the basis of the average of thresholds at 2000 and 4000 Hz for the same ear.
2. Should the mean hearing loss exceed 40 dB (HL) while speech can clearly be understood at 2
metres distance with each ear separately and without the use of a hearing-aid, hearing is
considered to be sufficient.

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2.5 Fitness criteria
The "Keuringsreglement voor de Zeevaart 2012" is based on the ILO/IMO "Guidelines on the
medical examination of seafarers". The physical requirements are set out in Appendix E of this
directive, see Annex 6.3. Based on this new directive, the Norwegian Centre for Maritime Medicine
(NCMM) have, in collaboration with the International Maritime Health Association (IMHA), written a
handbook on performing medical examinations for seafarers: http://handbook.ncmm.no/
Some common ailments where this handbook may be of aid are:

The use of anti-coagulantia

Refer to chapter 7, in particular the HAS-BLED Bleeding Risk Score:
http://handbook.ncmm.no/index.php/medication

Diabetes
The decision tree chapter 12:
http://handbook.ncmm.no/index.php/diabetes-and-its-treatment

Obesity
The decision tree chapter 13:
http://handbook.ncmm.no/index.php/obesity

Obesity increasingly leads to dangerous situations, such as seafarers unable to fit their rescue
suits, casualties too heavy to be taken into safety, or those short of breath after minor exercise.
Please note:

 BMI > 35: a maximum period of fitness of 12 months.

 BMI > 40: any declaration of fitness only after NSI consultation [email protected]

Hypertension
The decision tree chapter 16:
http://handbook.ncmm.no/index.php/blood-pressure-and-its-measurement

Tuberculosis
Seafarers may travel to areas where the risk of tuberculosis is considered much higher than it is in
The Netherlands. Also, crew often live and work close to each other and frequently team up with
crew who are possibly from higher prevalence TB areas.
Seafarers from TB risk areas should always be screened for tuberculosis. Other seafarers should be
screened if their anamnesis or physical examination indicates to do so. Risk areas are considered to
be any areas where the risk of infection is greater than the risk for the Dutch population in general,
and if the incidence of TB is higher than 50 cases per 100,000 inhabitants and determined as such
by the WHO. TB testing may be done by chest X-ray, Mantoux test or blood test (IGRA-test).

Tuberculosis risk areas

Refer to: http://gamapserver.who.int/mapLibrary/Files/Maps/gho_tb_incidence_2016.png

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2.6 Filling out the SMC
Seafarer classification
Four categories of seafarers are determined. The first three categories must comply with both
STCW-standards and the Maritime Labour Convention (MLC). The fourth category concerns
seafarers without look-out, watch, safety and security duties. This category does not need to
comply with STCW. They need only comply with MLC regulations.

Limitations on validity
When the examinee meets the standards determined in the final column of appendix E of the
ILO/IMO Guidelines on the medical examination of seafarers, and there is no medical indication for
a limited period of validity, ‘Until 2 years after the date of issue’ and ‘Worldwide’ may be ticked.
Limiting conditions may concern:
a) Limitation in time: tick third box ‘Period of validity’(Limited period otherwise), followed by the
period in months. Fill out date of expiry appropriately.
b) Area of validity: tick second box ‘Limited area’ and note restriction in miles off coast and/or
specific area. I.E.: ‘Within 30 miles of the Dutch coast’ or ‘Limited to The North Sea’.
c) Limitation on duties: under ‘Limitations on fitness’, note as required. I.E.: ‘No solo watch
keeping’.
d) Medical aids: under ‘Limitations on fitness’, note as required. I.E.: ‘Hearing aids are to be used
in both ears’.

Judgement medical fitness seafarer under STCW-Convention

For the first three categories tick either yes or no. In case of a category four examination, tick the
‘Not applicable’ box. Appendix A of the ILO/IMO Guidelines on the medical examination of seafarers
contains the STCW-code’s vision requirements. Appendix B contains the STCW-code’s hearing
requirements.
Testing of colour vision is only required for those with look-out or watch duties. (Either bridge or
engine room, category 1 and 2). Colour vision should be tested every six years. The date of testing
must be copied to the next certificate, unless the six years’ period expires during the date of
validity of the new certificate, in which case the colour vision test should be repeated.

Signature
Both seafarer and examining doctor should sign the SMC. Without both signatures the certificate
will be invalid.

Official stamp and name of the issuing authority

This is your name and stamp as recognized by The Netherlands Shipping Inspectorate.

Issue date and expiry date

Should additional examinations be required, the date of issue may be a later date than the original
date of examination. The expiry date is usually the date of issue + 24 months, unless a limited
period of validity is indicated.

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3 Medical examiners appointment and recognition
Medical examinations of shipping personnel for Dutch flag may only be carried out by physicians
appointed or recognised by the Minister of Infrastructure and Water Management.
Appointed doctors are qualified to issue SMC’s for all seafarers.
Recognized doctors are qualified to issue SMC’s solely for seafarers without any look-out or watch
duties, nor any safety or security duties.

The appointment is regulated in the Ships Manning Act and Ships Manning Order for merchant
ships and sailing vessels and the Ships Manning Order for fishing vessels respectively. Any request
is assessed on the Minister's behalf by the Medical Adviser of the Netherlands Shipping
Inspectorate.
During this assessment, due consideration is given to the regional requirement and the number of
medical examinations for shipping personnel that a physician expects to perform. During the
assessment of the application it is ascertained whether the physician is employed in a relevant area
in which general physical examination and the examination of the vision and hearing form part of
the day-to-day practice and whether the physician has experience in recognising diseases and
conditions.
The physician signs a declaration stating that he agrees with the aforementioned aspects and a
number of other conditions for appointment. It is important that he/she agrees to familiarize him or
herself with the various maritime professions, so that he/she is sufficiently familiar with the living
and working conditions onboard ships when performing the examinations. The examination
facilities should satisfy the quality requirements and the physician should be sufficiently available
and reachable. The medical examiner must have access to the Internet and an e-mail address.
The conditions stated in this declaration have been taken from the relevant articles in the Maritime
Crews Act, the Maritime Crews Decree and the Regulation for Medical Examinations of Shipping
Personnel 2012. As a result of this declaration there is no misunderstanding about the fact that the
medical examiner is aware of his formal rights and duties. The foreign physician signs the same
declaration as Dutch physicians and in addition to this a certificate of non-suspension.

For a general assessment of the professional competence of the physician, a visit can be part of the
appointment procedure, in addition to a test comparable to that taken by Dutch physicians
concerning professional expertise, practical experience and professional equipment. During this
visit, not only is the individual physician assessed, but attention is also paid to the following
aspects of the clinic or examination establishment: a valid quality system, recognition by the
national government, cooperation with subspecialists, the protection of privacy and the prevention
of fraud.
The authority to perform medical examinations on ships personnel is limited to a specific location
for medical examinations and is strictly personal. Even if some of the examinations are carried out
by third parties, the medical examiner remains responsible.
Medical declarations are valid only if they have been stamped with a name stamp recognized by
the Netherlands Shipping Inspectorate that is accompanied by a signature which is also known to
the NSI. An updated list of all appointed and recognized doctors will be published on www.ilent.nl

The appointment or recognition extends to a maximum of 5 years after the date on which it is
issued and will not be automatically renewed. After this period, any medical declaration issued will
not be valid. The medical examiner can only continue to perform medical examinations if he/she
has requested a new appointment or recognition in good time and was granted this.

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4 Additional information

4.1 Registering results

Registering issued medical certificates.
Each working day results must be reported via [email protected] .
The subject line of your e-mail should contain the doctor’s name.
The message should contain the seafarer’s full names and d.o.b.
Per working day only one concluding e-mail should be sent.

Registering declarations of unfitness

These must be reported via [email protected] , please add the declaration in pdf format.

For any questions or ordering of certificates, please use [email protected]

4.2 Surveillance
Periodical surveillance
Periodical audits of seafarers’examinig doctors is part of NSI’s inspection routines.

A typical audit will comprise of:

 Conversations with appointed or recognized doctors and staff;
 Discussing cases;
 Reviewing facilities and equipment;
 Reviewing medical files and means of archiving;
 Provide answers to possible questions and unclarities.

Findings
The auditee shall receive a review copy of the inspector’s report as soon as possible. A final report
shall be written and filed thereafter.
Any NSI instructions should be executed without delay.

4.3 Ordering certificates

Please order your by e-mail: [email protected]
You are requested to place a single order to cover an examination period of approximately six
months. Please allow a lead time of 14 days.

The forms:
‘Declaration of medical unfitness’ and ‘Medical examination form’ can be downloaded from our
website. https://english.ilent.nl/themes/medical-information/examinations

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5 Rules and regulations

5.1 Keuringsreglement voor de zeevaart

Ministerial Decree with respect to establishing the rules concerning the medical suitability and
medical examination of seafarers.

Article 1. Definitions
In this regulation the following terms shall have the following meanings:
a. act: Seafarers Act [Wet zeevarenden]
b. medical examination: medical examination as referred to in article 105, subsection 1, of the
Seafarers Merchant Shipping and Sailing Order [Besluit zeevarenden, handelsvaart en zeilvaart] or
article 61, subsection 1, of the Manning Order deep-sea fishing [Besluit zeevisvaartbemanning]
c. candidate: natural person who undergoes a medical examination
d. risk area: area outside of the Netherlands, where the risk of infection with tuberculosis is greater
than the infection risk for the Dutch population, as apparent from an annual prevalence of
tuberculosis in the country concerned which is higher than 50 cases per 100,000 inhabitants and
as determined by the World Health Organization.

Article 1a
1.The physician who is appointed by the minister complies with the conditions stated in Annex 4.
2.The physician who is recognized by the minister complies with the conditions stated in Annex 5.

Article 2. Items to be submitted and checked during the medical examination

1. Prior to the medical examination, the examining physician checks:
a. the candidate’s seaman’s book, or
b. if the candidate is not yet in the possession of a seaman’s book, the declaration by or on behalf
of the shipping company that the candidate is in service or will enter into service, accompanied by
valid identification, or
c. proof that the candidate has registered for a recognized nautical course, accompanied by valid
identification.
2. Furthermore, the examining physician checks:
a. the status of the seafarer’s examination, in order to check whether or not the examinee has
been declared unfit previously by another examining doctor;
b. if applicable, the result of a test for tuberculosis (chest X-ray, IGRA or Mantoux test);
c. if applicable, a valid dispensation, issued by the Medical Adviser of the Netherlands Shipping
Inspectorate as referred to in Chapter 6 of the Seafarers Merchant Shipping and Sailing Order and
Chapter 7 of the Manning Order deep-sea fishing.

Article 3. Examination and medical survey

1. The medical examination takes place with due regard to the examination directions and in
accordance with the medical standards, stated in Annex 1, Annex 2, or Appendix A through E of
Guidelines on the medical examinations of seafarers/ International Labour Office, Sectoral Activities
Programme, International Migration Organization 2013 (ILO/IMO/JMS/2011/12) respectively.
2. During the medical examination the examining physician will make use of the Examination Form.
The examining physician will retain the Examination Form and any other documents related to the
examination, for the duration and in the manner determined by or pursuant to the Dutch Medical
Treatment Contracts Act.
3. The medical examination of the general physical suitability comprises an examination into
previously experienced diseases and accidents (anamnesis), inherited and chronic diseases which
occur in the family (family anamnesis), a general assessment of the candidate's mental state of
health, chemical urine tests, as well as a general examination of the body, eyes and ears in order
to determine whether the candidate satisfies the standards, as referred to in subsection 1 of this
article.

Article 4. Specialist report or partial examination

1. The examining physician requests information from the attending physician if, according to
Article 3.1, a specialist report is required or if there are doubts as to whether the standards have
been met. If there is insufficient information, the examining physician refers the candidate to a
specialist for an additional examination.
2. Once the information from the attending physician or the report from the additional examination
by a specialist has been received, the examining physician can complete the examination.

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Article 5. Issuing the declaration of fitness
1. The examining physician who has performed a medical examination for which the result is
favourable, will present the candidate with a Seafarers’ Medical Certificate. The certificate will state
the duty category, period of validity and area of validity.
2. The examining physician will authenticate the certificate with his signature and name stamp.

Article 6. Declaration of medical unfitness (DOMU)

1. If the Seafarers’ Medical Certificate is to be withheld, the examining physician will inform the
candidate of this and state the reason or reasons for the rejection.
2. Candidates can only be rejected if the entire medical examination has been carried out in
accordance with articles 3 and 4.
3. The examining physician also informs the candidate of his right to a re-examination.
4. For each rejection for maritime service, the examining physician immediately informs the
Medical Adviser of the Netherlands Shipping Inspectorate using the ‘DOMU’, and stating the reason
or reasons for the rejection.
5. The examining physician presents the candidate with a copy of the ‘DOMU’ and on this states the
reason or reasons for the rejection.
6. If during an interim examination on the basis of article 23 of the act the examining physician
notices that the candidate is temporarily or permanently unfit for maritime service, he will proceed
as prescribed in subsections 1 to 5 of this article.
7. The candidate who wants a re-examination will approach a referee and submit his copy of the
‘DOMU’.

Article 7. Re-examination
1. After a declaration of temporary unfitness has been issued, a re-examination can only be
performed by the examining physician who rejected the candidate in the first place, unless the
candidate wishes to make use of his right to re-examination by an appointed referee.
2. After a declaration of permanent unfitness has been issued, a re-examination can only be
performed by an appointed referee.

Article 8. Procedure to be followed by arbitrator during a re-examination

1. For the re-examination, articles 3 and 4 are equally applicable, with the understanding that the
elements for which the candidate has already been declared fit by the examining physician during
the medical examination do not need to be repeated, unless there are doubts about the result.
2. In some cases the re-examination can solely consist of assessing the medical data available.
3. In the case of a declaration of fitness, article 5 is equally applicable.
4. In the case of rejection, subsections 1 and 5 of article 6 are equally applicable.
5. For the issuing of a dispensation, the referee sends a recommendation to the Medical Adviser of
the Netherlands Shipping Inspectorate.

Article 9. [deleted]

Article 10. Recording the results of the medical examination

The results of the medical examinations are recorded by the examining physician in the designated
register, with due consideration to the instructions from the Medical Adviser of the Netherlands
Shipping Inspectorate, and are kept for the period decreed by the Adviser.

Article 11. Forms

1. The model of the Seafarers’ Medical Certificate is the model as included in Annex 3.
2. For the Seafarers’ Medical Certificate, the Declaration of medical unfitness and the Examination
form, the examining physician will solely use the forms that are provided to him by the Medical
Adviser of the Netherlands Shipping Inspectorate.

Article 12.
This decree is based on articles 104, 106, first, second and third member, and 110, seventh
member, of the ‘Besluit zeevarenden handelsvaart en zeilvaart’ and articles 60, third member, 62,
first, second and third member of the ‘Besluit zeevisvaartbemanning.’

Article 13.
This decree shall be cited as: Keuringsreglement voor de Zeevaart 2012.

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Annex 1

Examination directions
The maintenance and promotion of the safety at sea entail inter alia conscientious medical
examinations of those seafarers to whom Dutch legislation applies. In general, the person involved
should be free from any abnormality, disease or injury which obstructs a safe performance of the
duties in order to qualify for a medical certificate. In this respect it is of particular importance to
promptly recognize and treat (or have treated) those disorders which clearly increase the risk to
the safety on board.
A seafarer with safely and/or security duties should at all times be able to act adequately in case of
an emergency. He must not only be able to bring himself in a safe position, he must also be able to
assist in extinguishing a fire, the launching of life-saving devices and the assistance of crew
members and passengers. Furthermore, his (her) presence may cause no danger to the health of
the other persons on board.

Assessment of an experienced seafarer

To those who have performed a maritime job for a length of time, it is reasonable to be flexible in a
number of cases. The issue of a Seafarer medical certificate, incidentally and in an individual case,
when there are grounds for unfitness, requires that agreement has been reached upon this
beforehand with the Medical Adviser of the Netherlands Shipping Inspectorate.

Consultating the medical adviser

If the assessment of fitness or the degree of unfitness gives rise to doubts, consultations should be
held with the Medical Adviser of the Netherlands Shipping Inspectorate.

Specific working conditions on board

In conducting the examination, the examining doctor should give consideration to the specific
working conditions on board, which depending on the vessel type and sailing area may vary greatly
though:
a. the pattern of work on board exhibits physical and mental peaks at irregular intervals;
b. the work on board is not infrequently performed in bad weather conditions or powerful winds
and in alternating cold and hot circumstances;
c. depending on the vessel type one has to work in more or less restless surroundings with much
background noise and movement;
d. work on board is accompanied by considerable physical stress, in addition to which plenty of
going upstairs and downstairs, maneuvering among obstacles and limited room for movement with
sometimes an unfavorable position during work, bring along additional stress to the musculo-
skeletal system;
e. the nature of duties is such that there is not always an opportunity to eat and sleep at regular
times, and
f. the number of crew members on board has reduced considerably compared to the past. If a
person on board is out of circulation through ill-health, his job has to be taken over by colleagues.

Vigilance and concentration

Regarding the medical examination of seafarers with safety and/or security duties it is also
important to realize that many activities on board call for constant alertness:
a. navigating, whereby particular alertness is called for when sailing at night, in fog or in bad
weather conditions;
b. watch keeping in the engine room, particularly in so-called "stand-by" situations, which call for
constant alertness in order to be able to maneuver at any given moment;
c. working with and being responsible for the transport of dangerous goods;
d. working on and in the vicinity of machinery with moving parts, such as cranes, winches and
windlasses etc.;
e. the performance of work on electrical wiring and steam conduits, and
f. the performance of work a great heights both inside and outside deep holds.

15
Limited medical care on board
It should be borne in mind that if careless examination for example results in an ulcer or inguinal
hernia being overlooked, the life of the seafarer may be endangered if he suffers a severe stomach
hemorrhage or if his inguinal hernia becomes strangulated. Adequate medical assistance is very
remote at such a moment. It is therefore important to recognize during the examination the
disorders for which treatment is to be expected. Thus one, for example, has to reckon with the
limited -and often late- opportunities for dental assistance.

Risk of infection
Seafarers are living close together for quite a long time. Infectious diseases are therefore a serious
problem and may endanger the safety of the vessel. Especially during the examination of personnel
which is involved in preparing food and catering extra attention has to be paid to it.

Safety
Wearing personal protective means must be possible without any problem and must not be
obstructed by physical disorders or restrictions. One should think in this case of safety helmets
and safety goggles, masks, ear protection, safety shoes and physical condition. Wearing a
compressed-air apparatus of 15 kg for minimally 20 minutes requires a good physical condition.
Heavy protective clothing is worn. While extinguishing a fire one has to work under great pressure
in a warm environment, often maneuvering through narrow holes and corridors.

Examination directions, directives for rejection, medical standards

In addition to the examination directions in this Annex 1 and the directives for rejection given
below, the medical standards in Annex 2 and appendix A - E from the Guidelines on the medical
examinations of seafarers/ International Labour Office, Sectoral Activities Programme, International
Migration Organization 2013 (ILO/IMO/JMS/2011/12) should be applied during the examination of
seafarers.

Directions for rejection

Medically unfit for service at sea is the person who suffers from a disease, abnormality or injury:
a. which can obstruct a safe performance of duties;
b. because of which the seafarer is not at all times able to act adequately in case of an emergency;
c. which may deteriorate during his stay on board, in such a way that this causes an unacceptable
risk to the health or safety of himself or other crewmembers, or a serious nuisance to other
persons on board;
d. which needs a treatment, which requires prolonged medical supervision or
which can necessitate immediate medical intervention, or
e. which can endanger the health of other crewmembers.

Annex 2
Instructions regarding seafarers without look-out duties and without safety or security duties .
(Only non-STCW, category 4 personnel).

Eyes and vision

1. Visual acuteness is assessed with the help of the Chart of Landolt TNO, the Snellen character
chart or another test which may be considered to be equivalent. With both eyes simultaneously, if
necessary with own (spare) glasses or contact lenses, a vision of 0.1 should be reached.
2. If optic correction devices have been used at the examination, adequate spare glasses must be
shown to the medical examiner.

Ears and hearing

1. A test with the tone audiometer is performed once every 2 years. A hearing loss of an average
of 40 dB (HL) for the best performing ear is a reason for unfitness. A hearing loss of an average of
40 dB (HL) or more for the worst ear is a reason for unfitness. The applicable norm is the
arithmetic mean of the unmasked conducting thresholds at 500, 1000, 2000 and 3000 Hz. If the
equipment does not allow for measurement at 3000 Hz, the threshold at 3000 Hz per ear may be
calculated on the basis of the average of thresholds at 2000 and 4000 Hz for the same ear.
2. Should the mean hearing loss exceed 40 dB (HL) while speech can clearly be understood at 2
metres distance with each ear separately and without the use of a hearing-aid, hearing is
considered to be sufficient.

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Annex 3

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5.2 Appendix A through E of the ILO/IMO guidelines

19
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 Appendix A
Vision standards

Testing
All tests needed to determine the visual fitness of a seafarer are to be reliably performed
by a competent person and use procedures recognized by the relevant national authority.
Quality assurance of vision-testing procedures at a person’s first seafarer examination
is particularly important to avoid inappropriate career decisions; competent authorities
may wish to specify this in detail:
– Distance vision should be tested using Snellen test type or equivalent.
– Near vision should be tested with reading test type.
– Colour vision should be tested by colour confusion plates (Ishihara or equivalent).
Supplementary investigations such as lantern tests may be used when appropriate (see
the International Recommendations for Colour Vision Requirements for Transport
of the International Commission on Illumination (CIE-143-2001, including any sub-
sequent versions)). The use of colour-correcting lenses will invalidate test results and
should not be permitted.
– Visual fields may initially be assessed using confrontation tests (Donders, etc.) and
any indication of limitation or the presence of a medical condition where visual field
loss can occur should lead to more detailed investigation.
– Limitations to night vision may be secondary to specific eye diseases or may follow
ophthalmological procedures. They may also be noted during other tests or found as
a result of limitations to low-contrast vision testing. Specialist assessment should be
undertaken if reduced night vision is suspected.

Visual correction
Medical practitioners should advise persons required to use spectacles or contact lenses
to perform duties that they should have a spare pair or pairs, as required, conveniently
available on board the ship.

Additional guidance
If laser refractive surgery has been undertaken, recovery should be complete and the
quality of visual performance, including contrast, glare sensitivity and the quality of
night vision, should have been checked by a specialist in ophthalmology.
All seafarers should achieve the minimum eyesight standard of 0.1 unaided in each eye
(STCW Code, section B-I/9, paragraph 10). This standard may also be relevant to other
seafarers to ensure visual capability under emergency conditions when visual correction
may be lost or damaged.
Seafarers not covered by the STCW Convention’s eyesight standards should have vision
sufficient to perform their routine and emergency duties safely and effectively.

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Guidelines on the medical examinations of seafarers

STCW Code table A-I/9: Minimum in-service eyesight standards for seafarers

STCW Category Distance Near/intermediate Colour Visual Night Diplopia

Convention of seafarer vision aided 1 vision vision 3 fields 4 blindness 4 (double
regulation vision) 4
One Other Both eyes together,
eye eye aided or unaided

I/11 Masters, deck 0.5 2 0.5 Vision required for ship’s See Normal Vision required No significant
II/1 officers and ratings navigation (e.g. chart and Note 6 visual to perform all condition
II/2 required to undertake nautical publication reference, fields necessary functions evident
II/3 look-out duties use of bridge instrumentation in darkness without
II/4 and equipment, and identifi- compromise
II/5 cation of aids to navigation)
VII/2
I/11 All engineer officers, 0.4 5 0.45 Vision required to read in- See Sufficient Vision required No significant
III/1 electro-technical struments in close proximity, Note 7 visual to perform all condition
III/2 officers, electro-tech- to operate equipment, and to fields necessary functions evident
III/3 nical ratings and identify systems/components in darkness without
III/4 ratings or others as necessary compromise
III/5 forming part of an
III/6 engine-room watch
III/7
VII/2
I/11 GMDSS radio 0.4 0.4 Vision required to read in- See Sufficient Vision required No
IV/2 operators struments in close proximity, Note 7 visual to perform all significant
to operate equipment, and to fields necessary functions condition
identify systems/components in darkness without evident
as necessary compromise
Notes:
1
Values given in Snellen decimal notation.
2
A value of at least 0.7 in one eye is recommended to reduce the risk of undetected underlying eye disease.
3
As defined in the International Recommendations for Colour Vision Requirements for Transport by the Commission Internationale de l’Eclairage (CIE-143-2001, including any
subsequent versions).
4
Subject to assessment by a clinical vision specialist where indicated by initial examination findings.
5
Engine department personnel shall have a combined eyesight vision of at least 0.4.
6
CIE colour vision standard 1 or 2.
7
CIE colour vision standard 1, 2 or 3.

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 Appendix B
Hearing standards

Testing
Hearing capacity for seafarers apart from those identified below should be an average of
at least 30 dB (unaided) in the better ear and an average of 40 dB (unaided) in the less
good ear within the frequencies 500, 1,000, 2,000 and 3,000 Hz (approximately equiva-
lent to speech-hearing distances of 3 metres and 2 metres, respectively).
It is recommended that hearing examinations should be made by a pure tone audiometer.
Alternative assessment methods using validated and standardized tests that measure im-
pairment to speech recognition are also acceptable. Speech and whisper testing may be
useful for rapid practical assessments. It is recommended that those undertaking deck/
bridge duties are able to hear whispered speech at a distance of 3 metres.
Hearing aids are only acceptable in serving seafarers where it has been confirmed that
the individual will be capable of safely and effectively performing the specific routine
and emergency duties required of them on the vessel that they serve on throughout the
period of their medical certificate. This may well require access to a back-up hearing
aid and sufficient batteries and other consumables. Arrangements need to be in place to
ensure that they will be reliably aroused from sleep in the event of an emergency alarm.
If noise-induced hearing loss is being assessed as part of a health surveillance pro-
gramme, different criteria and test methods will be required.
It is recommended that national authorities indicate which tests for hearing are to be
used, based on national audiological practices, using the above thresholds as criteria.
Procedures should include the methods to be adopted in deciding if the use of a hearing
aid is acceptable.

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Guidelines on the medical examinations of seafarers

Appendix C
Physical capability requirements

Introduction
The physical capability requirements for work at sea vary widely and have to take ac-
count of both routine and emergency duties. The functions that may require assessment
include:
– strength;
– stamina;
– flexibility;
– balance and coordination;
– size – compatible with entry into confined areas;
– exercise capacity – heart and respiratory reserve; and
– fitness for specific tasks – wearing breathing apparatus.

Medical conditions and physical capability

Limitations may arise from a range of conditions, such as:
– high or low body mass/obesity;
– severely reduced muscle mass;
– musculoskeletal disease, pain or limitations to movement;
– a condition following an injury or surgery;
– lung disease;
– heart and blood vessel disease; and
– some neurological diseases.

Physical capability assessment

Physical capability testing should be undertaken when there is an indication for it, for
instance because of the presence of one of the above conditions or because of other con-
cerns about a seafarer’s physical capabilities. The aspects that are tested will depend on
the reasons for doing it. Table B-I/9 gives recommendations for physical abilities to be
assessed for those seafarers covered by the STCW Convention, 1978, as amended, based
on the tasks undertaken at sea.
The following approaches may be used to assess whether the requirements in Table B-I/9
are met:
– Observed ability to do routine and emergency duties in a safe and effective way.
– Tasks that simulate normal and emergency duties.
– Assessment of cardio-respiratory reserve, including spirometry and ergometric tests.
This will predict maximum exercise capacity and hence the seafarer’s ability to per-
form physically demanding work. A large reserve will also indicate that heart and
lung performance is less likely to be compromised in the next few years. The bench-
mark test is maximum oxygen uptake (VO2 max). This requires dedicated equipment.

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 Appendix C

Step tests such as the Chester or the Harvard, are simpler alternatives, which may be
used for screening. If step tests are abnormal, they should be further validated (e.g.
VO2 max or treadmill stress tests).
– Informal testing of reserve, for instance climbing three to six flights of stairs and
assessing any distress, plus the speed of pulse rate decline on stopping. This is not
readily reproducible but can be used for repeat assessment at the same location by the
same medical practitioner.
– Clinical assessment of strength, mobility, coordination, etc.
Additional information may come from activities recently or regularly undertaken, as
described by the seafarer, such as:
– physically demanding duties on the vessel, e.g. carrying weights or handling mooring
equipment;
– attendance at a physically demanding course within the last two years, e.g. firefighting,
helicopter escape or STCW basic training; and
– a confirmed personal pattern of regular strenuous exercise.

Interpretation of results
(1) Is there any evidence that the seafarer is not able to perform their routine and emer-
gency duties effectively?
(2) Are there any observed limitations to strength, flexibility, stamina or coordination?
(3) What is the outcome of any test for cardio-respiratory reserve?
(i) Test performance limited by shortness of breath, musculoskeletal or other pain,
or exhaustion. Causes need to be investigated and taken into account in deter-
mining fitness.
(ii) Unable to complete test.
(iii) Completed but stressed or with poor recovery after stopping.
(iv) Completed to good or average standard.
(4) Discuss subjective feelings during the test with the subject and also go over ex-
periences of fitness and capability when doing normal tasks and emergency drills.
Obtain corroboration from others if performance at work uncertain.

Decision-making
Information from a range of sources may be required and many of these are not easily
accessed in the course of a medical examination:
(1) Is there any indication that physical capability may be limited (e.g. stiffness, obesity
or history of heart disease)?
(i) No – do not test.
(ii) Yes – consider what tests or observations will enable the seafarer’s capability to
perform their routine and emergency duties to be determined. Go to (2).
(2) Do the test results indicate that capabilities may be limited?
(i) No – provided there are no underlying conditions that affect conduct of assess-
ment. Able to perform all duties worldwide within designated department.
(ii) Yes – but duties can be modified to enable safe working, without putting excess
responsibilities on others. Able to perform some but not all duties (R).
(iii) Yes – but cause of limitation can be remedied. Incompatible with reliable per-
formance of essential duties safely or effectively (T).
(iv) Yes – but cause of limitation cannot be remedied. Incompatible with reliable
performance of essential duties safely or effectively (P).

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Guidelines on the medical examinations of seafarers

Table B-I/9: Assessment of minimum entry level and in-service physical abilities for seafarers³

Shipboard task, function, Related physical ability A medical examiner should be

event or condition 3 satisfied that the candidate: 4

Routine movement around vessel: • Maintain balance and move with agility • Has no disturbance in sense of balance
– on moving deck • Climb up and down vertical ladders and stairways • Does not have any impairment or disease that
– between levels • Step over coamings (e.g. Load Line Convention prevents relevant movements and physical
– between compartments requires coamings to be 600 mm high) activities
• Open and close watertight doors • Is, without assistance, 5 able to:
– climb vertical ladders and stairways
– step over high sills
Note 1 applies to this row – manipulate door closing systems

Routine tasks on board: • Strength, dexterity and stamina to manipulate • Does not have a defined impairment or diag-
– use of hand tools mechanical devices nosed medical condition that reduces ability
– movement of ship’s stores • Lift, pull and carry a load (e.g. 18 kg) to perform routine duties essential to the safe
– overhead work • Reach upwards operation of the vessel
• Stand, walk and remain alert for an extended period • Has ability to:
– valve operation
• Work in constricted spaces and move through – work with arms raised
– standing a four-hour watch
restricted openings (e.g. SOLAS regulation 11-I/3- – stand and walk for an extended period
– working in confined spaces – enter confined space
– responding to alarms, 6.5.1 requires openings in cargo spaces and emer-
gency escapes to have the minimum dimensions of – fulfil eyesight standards (table A-I/9)
warnings and instructions – fulfil hearing standards set by competent
600 mm × 600 mm)
– verbal communication authority or take account of international
• Visually distinguish objects, shapes and signals
guidelines
• Hear warnings and instructions – hold normal conversation
Note 1 applies to this row • Give a clear spoken description

Emergency duties6 on board: • Don a lifejacket or immersion suit • Does not have a defined impairment or diag-
– escape • Escape from smoke-filled spaces nosed medical condition that reduces ability to
– firefighting • Take part in fire-fighting duties, including use of perform emergency duties essential to the safe
– evacuation breathing apparatus operation of the vessel
• Take part in vessel evacuation procedures • Has ability to:
– don lifejacket or immersion suit
– crawl
– feel for differences in temperature
– handle fire-fighting equipment
– wear breathing apparatus
Note 2 applies to this row (where required as part of duties)

Notes:
1
Rows 1 and 2 of the above table describe: (a) ordinary shipboard tasks, functions, events and conditions; (b) the corresponding physical abilities which may be considered
necessary for the safety of a seafarer, other crew members and the ship; and (c) high-level criteria for use by medical practitioners assessing medical fitness, bearing in mind
the different duties of seafarers and the nature of shipboard work for which they will be employed.
2
Row 3 of the above table describes: (a) emergency shipboard tasks, functions, events and conditions; (b) the corresponding physical abilities which should be considered
necessary for the safety of a seafarer, other crew members and the ship; and (c) high-level criteria for use by medical practitioners assessing medical fitness, bearing in mind
the different duties of seafarers and the nature of shipboard work for which they will be employed.
3
This table is not intended to address all possible shipboard conditions or potentially disqualifying medical conditions. Parties should specify physical abilities applicable to the
category of seafarers (such as “deck officer” and “engine rating”). The special circumstances of individuals and for those who have specialized or limited duties should receive
due consideration.
4
If in doubt, the medical practitioner should quantify the degree or severity of any relevant impairment by means of objective tests, whenever appropriate tests are available, or
by referring the candidate for further assessment.
5
The term “assistance” means the use of another person to accomplish the task.
6
The term “emergency duties” is used to cover all standard emergency response situations such as abandon ship or firefighting as well as the procedures to be followed by
each seafarer to secure personal survival.

2018 Revision 1 25
 Appendix D
Fitness criteria for medication use

Introduction
Medication can play an important part in enabling seafarers to continue to work at sea.
Some have side effects that can affect safe and effective performance of duties and some
have other complications that will increase the likelihood of illness at sea.
This appendix is only concerned with continuing prescribed medication use that is iden-
tified at the medical examination. Ship operators need policies in place to reduce the
impairing effects from short-term use of prescribed medication or the use of over-the-
counter preparations.
The use of oral medication at sea may be prevented by nausea and vomiting, and illness
may arise if an oral medication is used to suppress the harmful effects of a condition (e.g.
epilepsy) or if it is used to replace essential body chemicals (e.g. hormones).
The examining medical practitioner will need to assess the known adverse effects of each
medication used and the individual’s reaction to it.
The use of specific medication for some conditions listed in Appendix E is noted with
the condition.
If medication is clinically essential for the effective control of a condition, e.g. insulin,
anticoagulants and medication for mental health conditions, it is dangerous to stop it in
an attempt to be fit for work at sea.
The medical practitioner should be alert to the need for the seafarer to have written
documentation for the use of their medications. This should be in a form that can be
shown to any official who may question the presence of the medication on board. This is
particularly important for those medications that are legally prescribed controlled drugs
or those drugs which may be abused.

Medications that can impair routine and emergency duties

(1) Medication affecting the central nervous system functions (e.g. sleeping tablets, an-
tipsychotics, some analgesics, some anti-anxiety and anti-depression treatments and
some antihistamines).
(2) Agents that increase the likelihood of sudden incapacitation (e.g. insulin, some of
the older anti-hypertensives and medications predisposing to seizures).
(3) Medication impairing vision (e.g. hyoscine and atropine).

Medications that can have serious adverse consequences

for the user while at sea
(1) Bleeding from injury or spontaneously (e.g. warfarin); individual assessment of like-
lihood needed. Anticoagulants such as warfarin or dicoumarin normally have a
likelihood of complications that is incompatible with work at sea but, if coagulation
values are stable and closely monitored, work that is near to onshore medical facil-
ities and that does not carry an increased likelihood of injury may be considered.

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Guidelines on the medical examinations of seafarers

(2) Dangers from cessation of medication use (e.g. metabolic replacement hormones
including insulin, anti-epileptics, anti-hypertensives and oral anti-diabetics).
(3) Antibiotics and other anti-infection agents.
(4) Anti-metabolites and cancer treatments.
(5) Medications supplied for use at individual discretion (asthma treatments and anti-
biotics for recurrent infections).

Medications that require limitation of period at sea

because of surveillance requirements
A wide range of agents, such as anti-diabetics, anti-hypertensives and endocrine
replacements.

Issue of medical certificates

Incompatible with the reliable performance of routine and emergency duties safely or
effectively:
– on the recommendation of the examining medical practitioner, based on reliable in-
formation about severe impairing side effects;
– oral medication where there are life-threatening consequences if doses are missed
because of sickness;
– evidence indicating the likelihood of cognitive impairment when taken as prescribed;
– established evidence of severe adverse effects likely to be dangerous at sea,
e.g. anticoagulants.
Able to perform some but not all duties or to work in some but not all waters:
(R): medication can cause adverse effects but these only develop slowly, hence work in
coastal waters will allow access to medical care.
(L): surveillance of medication effectiveness or side effects needed more frequently
that full duration of medical certificate (see guidelines on individual conditions in
Appendix E).

Able to perform all duties worldwide within designated department:

No impairing side effects; no requirements for regular surveillance of treatment.

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 Appendix E
Fitness criteria for common
medical conditions

Introduction
The medical practitioner should bear in mind that it is not possible to develop a compre-
hensive list of fitness criteria covering all possible conditions and the variations in their
presentation and prognosis. The principles underlying the approach adopted in the table
below may often be extrapolated to conditions not covered by it. Decisions on fitness
when a medical condition is present depend on careful clinical assessment and analysis
and the following points need to be considered whenever a decision on fitness is taken:
– The recommendations in this appendix are intended to allow some flexibility of inter-
pretation while being compatible with consistent decision-making that aims to main-
tain safety at sea.
– The medical conditions listed are common examples of those that may render sea-
farers unfit. The list can also be used to determine appropriate limitations to fitness.
The criteria given can only provide guidance for physicians and should not replace
sound medical judgement.
– The implications for working and living at sea vary widely, depending on the natural
history of each condition and the scope for treatment. Knowledge about the condition
and an assessment of its features in the individual being examined should be used to
reach a decision on fitness.
The table in this appendix is laid out as follows:
Column 1: WHO International Classification of Diseases, 10th revision (ICD-10). Codes
are listed as an aid to analysis and, in particular, international compilation
of data.
Column 2: The common name of the condition or group of conditions, with a brief
statement on its relevance to work at sea.
Column 3: The guideline recommending when work at sea is unlikely to be indicated,
either temporarily or permanently. This column should be consulted first
when the table is being used to aid decisions about fitness.
Column 4: The guideline recommending when work at sea may be appropriate but
when restriction of duties or monitoring at intervals of less than two years
is likely to be appropriate. This column should be consulted if the seafarer
does not fit the criteria in column 3.
Column 5: The guideline recommending when work at sea within a seafarer’s desig-
nated department is likely to be appropriate. This column should be con-
sulted if the seafarer does not fit the criteria in columns 3 or 4.
For some conditions, one or more columns are either not relevant or are not an appro-
priate certification category. These are identified by the term “Not applicable”.

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 Guidelines on the medical examinations of seafarers
ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

A00–B99 Infections
A00–09 Gastrointestinal infection T – If detected while onshore (current symptoms Not applicable Non-catering department: When satisfactorily
Transmission to others, recurrence or awaiting test results on carrier status); or con- treated or resolved
firmed carrier status until elimination demonstrated Catering department: Fitness decision to be based
on medical advice – bacteriological clearance may
be required
A15–16 Pulmonary TB Transmission to others, T – Positive screening test or clinical history, until Not applicable Successful completion of a course of treatment in
recurrence investigated accordance with WHO Treatment of Tuberculosis
If infected, until treatment stabilized and lack of guidelines
infectivity confirmed
P – Relapse or severe residual damage
A50–64 Sexually transmissible infections T – If detected while onshore, until diagnosis con- R – Consider near coastal if oral treatment regime On successful completion of treatment
Acute impairment, recurrence firmed, treatment initiated and impairing symptoms in place and symptoms non-incapacitating
resolved
P – Untreatable impairing late complications
B15 Hepatitis A Transmissible by food or T – Until jaundice resolved and liver function tests Not applicable On full recovery
water contamination returned to normal
B16–19 Hepatitis B, C, etc. Transmissible by T – Until jaundice resolved and liver function tests R, L – Uncertainty about total recovery or lack of On full recovery and confirmation of low level
contact with blood or other bodily fluids. returned to normal infectivity. Case-by-case decision-making based of infectivity
Possibility of permanent liver impair- P – Persistent liver impairment with symptoms on duties and voyage patterns
ment and liver cancer affecting safe work at sea or with likelihood of
complications
B20–24 HIV+ Transmissible by contact with T – Until stabilized on treatment with CD4 level of R, L – Time limited and/or near coastal: HIV+ HIV+, no current impairment and very low*
blood or other bodily fluids. Progression > 350 or when treatment changed and tolerance of and low likelihood of progression; on no treatment likelihood of disease progression. No side
to HIV-associated diseases or AIDS new medication uncertain or on stable medication without side effects, but effects of treatment or requirements for frequent
P – Non-reversible impairing HIV-associated dis- requiring regular specialist surveillance surveillance
eases. Continuing impairing effects of medication
A00–B99 Other infections Personal impairment, T – If detected while onshore: until free from risk of Case-by-case decision based on nature of Full recovery and confirmation of low level
Not listed infection of others transmission and capable of performing duties infection of infectivity
separately P – If continuing likelihood of repeated impairing or
infectious recurrences

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 ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

C00–48 Cancers
C00–48 Malignant neoplasms – including T – Until investigated, treated and prognosis L – Time limited to interval between specialist Cancer diagnosed more than 5 years ago, or
lymphoma, leukaemia and related con- assessed reviews if: specialist reviews no longer required and no
ditions Recurrence – especially acute P – Continuing impairment with symptoms – cancer diagnosed < 5 years ago; and current impairment or low continuing likelihood of
complications, e.g. harm to self from affecting safe work at sea or with high likelihood of – there is no current impairment of performance impairment from recurrence
bleeding and to others from seizures recurrence of normal or emergency duties or living at sea; To be confirmed by specialist report with evidence
and for opinion stated
– there is a low likelihood of recurrence and
minimal risk of requirement for urgent medical
treatment
R – Restricted to near coastal waters if any
continuing impairment does not interfere with
essential duties and any recurrence is unlikely to
require emergency medical treatment
D50–89 Blood disorders
D50–59 Anaemia/Haemoglobinopathies T – Distant waters, until haemoglobin normal and R, L – Consider restriction to near coastal waters Normal levels of haemoglobin
Reduced exercise tolerance. Episodic stable and regular surveillance if reduced haemoglobin
red cell breakdown P – Severe recurrent or continuing anaemia or level but asymptomatic
impairing symptoms from red cell breakdown that
are untreatable
D73 Splenectomy (history of surgery) T – Post surgery until fully recovered R – Case-by-case assessment. Likely to be fit Case-by-case assessment
Increased susceptibility to certain for coastal and temperate work but may need
infections restriction on service in tropics
D50–89 Other diseases of the blood and T – While under investigation Case-by-case assessment for other conditions Case-by-case assessment

Appendix E
Not listed blood-forming organs Varied recur- P – Chronic coagulation disorders
separately rence of abnormal bleeding and also
possibly reduced exercise tolerance or
low resistance to infections

2018 Revision 1 30
 Guidelines on the medical examinations of seafarers
ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

E00–90 Endocrine and metabolic

E10 Diabetes – Insulin using Acute T – From start of treatment until stabilized R, L – Subject to evidence of good control, full Not applicable
impairment from hypoglycaemia. P – If poorly controlled or not compliant with compliance with treatment recommendations and
Complications from loss of blood treatment. History of hypoglycaemia or loss of good hypoglycaemia awareness
glucose control Increased likelihood hypoglycaemic awareness. Impairing complications Fit for near coastal duties without solo watch-
of visual, neurological and cardiac of diabetes keeping. Time limited until next specialist check-up.
problems Must be under regular specialist surveillance
E11–14 Diabetes – Non-insulin treated, on T – Distant waters and watchkeeping until R – Near coastal waters and non-watchkeeping When stabilized, in the absence of impairing
other medication Progression to insulin stabilized duties until stabilized complications
use, increased likelihood of visual, R – Near coastal waters, no solo watchkeeping
neurological and cardiac problems if minor side effects from medication. Especially
when using sulphonylureas
L – Time limited if compliance poor or medication
needs frequent review. Check diet, weight and
vascular risk factor control
Diabetes – Non-insulin treated, T – Distant waters and watchkeeping until R – Near coastal waters and non-watchkeeping When stabilized, in the absence of impairing
treated by diet alone Progression to in- stabilized duties until stabilized complications
sulin use, increased likelihood of visual, L – Time limited when stabilized, if compliance
neurological and cardiac problems poor. Check diet, weight and vascular risk factor
control
E65–68 Obesity/abnormal body mass – high T – If safety-critical duties cannot be performed, R, L – Time limited and restricted to near coastal Capability and exercise test (Appendix E)
or low Accident to self, reduced mobility capability or exercise test (Appendix C) perfor- waters or to restricted duties if unable to perform performance average or better, weight steady or
and exercise tolerance for routine and mance is poor certain tasks but able to meet routine and reducing and no co-morbidity
emergency duties. Increased likelihood P – Safety-critical duties cannot be performed; emergency capabilities for assigned safety-critical
of diabetes, arterial diseases and capability or exercise test performance is poor with duties
arthritis failure to achieve improvements
Note: Body mass index is a useful indicator of
when additional assessment is needed. National
norms will vary. It should not form the sole basis
for decisions on capability

2018 Revision 1 31
 ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

E00–90 Other endocrine and metabolic T – Until treatment established and stabilized R, L – Case-by-case assessment with specialist If medication stable with no problems in taking
Not listed disease (thyroid, adrenal including without adverse effects advice if any uncertainty about prognosis or side at sea and surveillance of conditions infre-
separately Addison’s disease, pituitary, ovaries, P – If continuing impairment, need for frequent effects of treatment. Need to consider likelihood of quent, no impairment and very low likelihood of
testes) Likelihood of recurrence or adjustment of medication or increased likelihood of impairing complications from condition or its treat- complications
complications major complications ment, including problems taking medication, and Addison’s disease: The risks will usually be such
consequences of infection or injury while at sea that an unrestricted certificate should not be issued
F00–99 Mental, cognitive and behavioural disorders

F10 Alcohol abuse (dependency) T – Until investigated and stabilized and criteria for R, L – Time limited, not to work as master in After three years from end of last episode without
Recurrence, accidents, erratic behav- fitness met. Until one year after initial diagnosis or charge of vessel or without close supervision and relapse and without co-morbidity
iour/safety performance one year after any relapse continuing medical monitoring, provided that:
P – If persistent or there is co-morbidity likely to treating physician reports successful participation
progress or recur while at sea in rehabilitation programme; and there is an
improving trend in liver function tests
F11–19 Drug dependence/persistent sub- T – Until investigated and stabilized and criteria for R, L – Time limited, not to work as master in After three years from end of last episode without
stance abuse, includes both illicit drug fitness met. Until one year after initial diagnosis or charge of vessel or without close supervision and relapse and without co-morbidity
use and dependence on prescribed one year after any relapse continuing medical monitoring, provided that:
medications Recurrence, accidents, P – If persistent or there is co-morbidity likely to – treating physician reports successful partici-
erratic behaviour/safety performance progress or recur while at sea pation in rehabilitation programme; and
– evidence of completion of unannounced/
random programme of drug screening for at

Appendix E
least three months with no positives and at
least three negatives; and
– continuing participation in drug screening
programme

2018 Revision 1 32
 Guidelines on the medical examinations of seafarers
ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

F20–31 Psychosis (acute) – whether organic, Following single episode with provoking factors: R, L – Time limited, restricted to near coastal Case-by-case assessment at least one year after
schizophrenic or other category listed in T – Until investigated and stabilized and conditions waters and not to work as master in charge of the episode, provided that provoking factors can
the ICD. Bipolar (manic depressive dis- for fitness met. At least three months after episode vessel or without close supervision and continuing and will always be avoided
orders) Recurrence leading to changes medical monitoring, provided that:
to perception/cognition, accidents, – seafarer has insight;
erratic and unsafe behaviour – is compliant with treatment; and
– has no adverse effects from medication
Following single episode without provoking factors R, L – Time limited, restricted to near coastal Case-by-case assessment to exclude likelihood of
or more than one episode with or without provoking waters and not to work as master in charge of recurrence at least five years since end of episode
factors: vessel or without close supervision and continuing if no further episodes; no residual symptoms; and
T – Until investigated and stabilized and condi- medical monitoring providing that: no medication needed during last two years
tions for fitness met. At least two years since last – the seafarer has insight;
episode – is compliant with treatment; and
– has no impairing adverse effects from
P – More than three episodes or continuing
medication
likelihood of recurrence. Criteria for fitness with or
without restrictions are not met
F32–38 Mood/affective disorders Severe T – While acute, under investigation or if impairing R, L – Restrict to near coastal waters and not Case-by-case assessment to exclude likelihood of
anxiety state, depression, or any other symptoms or side effects of medication present. At to work as master in charge of ship, only when recurrence after at least two years with no further
mental disorder likely to impair perfor- least three months on stable medication seafarers have: episodes and with no medication or on medication
mance Recurrence, reduced perfor- P – Persistent or recurrent impairing symptoms – good functional recovery; with no impairing effects
mance, especially in emergencies – insight;
– is fully compliant with treatment, with no
impairing side effects; and
– a low* likelihood of recurrence
Mood/affective disorders Minor or T – Until symptom free. If on medication to be on a R, L – Time limited and consider geographical Case-by-case assessment after one year from
reactive symptoms of anxiety/depres- stable dose and free from impairing adverse effects restriction if on stable dose of medication and free end of episode if symptom free and off medica-
sion Recurrence, reduced performance, P – Persistent or recurrent impairing symptoms from impairing symptoms or impairing side effects tion or on medication with no impairing effects
especially in emergencies from medication
F00–99 Other disorders, e.g. disorders of P – If considered to have safety-critical R – As appropriate if capable of only limited No anticipated adverse effects while at sea. No
Not listed personality, attention (e.g. ADHD), de- consequences duties incidents during previous periods of sea service
separately velopment (e.g. autism) Impairment of
performance and reliability and impact
on relationships

2018 Revision 1 33
 ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

G00–99 Diseases of the nervous system

G40–41 Single seizure Harm to ship, others Single seizure R – One year after seizure and on stable medi- One year after seizure and one year after end
and self from seizures T – While under investigation and for one year after cation. Non-watchkeeping duties in near coastal of treatment. If provoked, there should be no
seizure waters continuing exposure to the provoking agent

Epilepsy – No provoking factors T – While under investigation and for two years R – Off medication or on stable medication with Seizure-free for at least the last ten years, has
(multiple seizures) Harm to ship, others after last seizure good compliance: case-by-case assessment of not taken anti-epilepsy drugs during that ten-year
and self from seizures P – Recurrent seizures, not controlled by fitness, restricted to non-watchkeeping duties in period and does not have a continuing likelihood
medication near coastal waters of seizures

Epilepsy – provoked by alcohol, T – While under investigation and for two years R – Case-by-case assessment after two years’ Seizure-free for at least the last five years, has
medication, head injury (multiple after last seizure abstention from any known provoking factors, not taken anti-epilepsy drugs during that five-year
seizures) Harm to ship, others and self P – Recurrent fits, not controlled by medication seizure-free and either off medication or on stable period, provided there is not continuing exposure
from seizures medication with good compliance; restricted to to the provoking agent
non-watchkeeping duties in near coastal waters
G43 Migraine (frequent attacks causing P – Frequent attacks leading to incapacity R – As appropriate. If only capable of limited No anticipated incapacitating adverse effects
incapacity) Likelihood of disabling duties while at sea. No incidents during previous periods
recurrences of sea service
G47 Sleep apnoea Fatigue and episodes of T – Until treatment started and successful for three L – Once treatment demonstrably working Case-by-case assessment based on job and
sleep while working months effectively for three months, including compliance emergency requirements, informed by specialist
P – Treatment unsuccessful or not being complied with CPAP (continuous positive airway pressure) advice
with machine use confirmed. Six-monthly assessments
of compliance based on CPAP machine recording
Narcolepsy Fatigue and episodes of T – Until controlled by treatment for at least two R, L – Near coastal waters and no watchkeeping Not applicable
sleep while working years duties, if specialist confirms full control of treat-
P – Treatment unsuccessful or not being complied ment for at least two years
with Annual review
G00–99 Other organic nervous disease, T – Until diagnosed and stable R, L – Case-by-case assessment based on Case-by-case assessment based on job and

Appendix E
Not listed e.g. multiple sclerosis, Parkinson’s P – If limitations affect safe working or unable to job and emergency requirements, informed by emergency requirements, informed by specialist
separately disease Recurrence/progression. meet physical capability requirements (Appendix C) specialist advice advice
Limitations on muscular power, bal-
ance, coordination and mobility

2018 Revision 1 34
 Guidelines on the medical examinations of seafarers
ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

R55 Syncope and other disturbances of T – Until investigated to determine cause and to
consciousness Recurrence causing demonstrate control of any underlying condition
injury or loss of control Event is:
(a) simple faint; Simple faint; if no incapacitating recurrences
(b) not a simple faint; unexplained disturbance, R, L – Case-by-case decision, near coastal with Three months after event if no recurrences
not recurrent and without any detected underlying no lone watchkeeping
cardiac, metabolic or neurological cause
T – Four weeks
(c) Disturbance; recurrent or with possible under- R, L – Case-by-case decision, near coastal with With possible underlying cause but no treat-
lying cardiac, metabolic or neurological cause no lone watchkeeping able cause found; one year after event if no
T – With possible underlying cause that is not recurrences
identified or treatable; for six months after event if With possible underlying cause found and treated;
no recurrences three months after successful treatment
T – With possible underlying cause or cause
found and treated; for one month after successful
treatment
(d) Disturbance of consciousness with features With seizure markers – not applicable
indicating a seizure. Go to G40–41
P – For all of above if recurrent incidents persist
despite full investigation and appropriate treatment
T90 Intracranial surgery/injury, including T – For one year or longer until seizure likelihood R – After at least one year, near coastal, no lone No impairment from underlying condition or
treatment of vascular anomalies or low,* based on advice from specialist watchkeeping if seizure likelihoods low* and no injury, not on anti-epilepsy medications. Seizure
serious head injury with brain damage P – Continuing impairment from underlying condi- impairment from underlying condition or injury likelihood very low*
Harm to ship, others and self from tion or injury or recurrent seizures Conditional on continued compliance with any Conditional on continued compliance with any
seizures. Defects in cognitive, sensory treatment and on periodic review, as recom- treatment and on periodic review, as recom-
or motor function. Recurrence or com- mended by specialist mended by specialist
plication of underlying condition
H00–99 Diseases of the eyes and ears
H00–59 Eye disorders: Progressive or recur- T – Temporary inability to meet relevant vision R – Near coastal waters if recurrence unlikely Very low likelihood of recurrence. Progression to a
rent (e.g. glaucoma, maculopathy, dia- standards (Appendix A) and low likelihood of sub- but foreseeable and treatable with early medical level where vision standards (Appendix A) are not
betic retinopathy, retinitis pigmentosa, sequent deterioration or impairing recurrence once intervention met during period of certificate is very unlikely
keratoconus, diplopia, blepharospasm, treated or recovered L – If risk of progression foreseeable but unlikely
uveitis, corneal ulceration and retinal P – Inability to meet relevant vision standards and can be detected by regular monitoring
detachment) Future inability to meet (Appendix A) or, if treated, increased likelihood of
vision standards, risk of recurrence subsequent deterioration or impairing recurrence

2018 Revision 1 35
 ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

H65–67 Otitis – External or media T – Until treated Case-by-case assessment. Consider effects of Effective treatment and no excess likelihood of
Recurrence, risk as infection source in P – If chronic discharge from ear in food handler heat, humidity and hearing protection use in otitis recurrence
food handlers, problems using hearing externa
protection
H68–95 Ear disorders: Progressive T – Temporary inability to meet relevant hearing L – If risk of progression foreseeable but unlikely Very low likelihood of recurrence. Progression to a
(e.g. otosclerosis) standards (Appendix B) and low likelihood of sub- and it can be detected by regular monitoring level where hearing standards (Appendix B) are
sequent deterioration or impairing recurrence once not met during period of certificate is very unlikely
treated or recovered
P – Inability to meet relevant hearing standards
(Appendix B) or, if treated, increased likelihood or
subsequent deterioration or impairing recurrence
H81 Ménière’s disease and other forms of T – During acute phase R – As appropriate. If only capable of limited Low* likelihood of impairing effects while at sea
chronic or recurrent disabling vertigo P – Frequent attacks leading to incapacity duties
Inability to balance, causing loss of R, L – If frequent specialist surveillance required
mobility and nausea See STCW table in
Appendix C
I00–99 Cardiovascular system

I05–08 Congenital and valve disease of T – Until investigated and, if required, treated R – Near coastal waters if case-by-case Heart murmurs – Where unaccompanied by other
I34–39 heart (including surgery for these con- P – If exercise tolerance limited or episodes of assessment indicates either likelihood of acute heart abnormalities and considered benign by a
ditions) Heart murmurs not previously incapacity occur or if on anticoagulants or if per- complications or rapid progression specialist cardiologist following examination
investigated Likelihood of progression, manent high likelihood of impairing event L – If frequent surveillance is recommended Other conditions – Case-by-case assessment
limitations on exercise based on specialist advice
I10–15 Hypertension Increased likelihood of T – Normally if >160 systolic or >100 diastolic mm L – If additional surveillance needed to ensure If treated in accordance with national guidelines
ischemic heart disease, eye and kidney Hg until investigated and treated in accordance level remains within national guideline limits and free from impairing effects from condition or

Appendix E
damage and stroke. Possibility of acute with national or international guidelines for hyper- medication
hypertensive episode tension management
P – If persistently >160 systolic or >100 diastolic
mm Hg with or without treatment

2018 Revision 1 36
 Guidelines on the medical examinations of seafarers
ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

I20–25 Cardiac event, i.e. myocardial infarc- T – For three months after initial investigation and L – If excess likelihood of recurrence is very low* Not applicable
tion, ECG evidence of past myocardial treatment, longer if symptoms not resolved and fully compliant with risk reduction recom-
infarction or newly recognized left P – If criteria for issue of certificate not met mendations and no relevant co-morbidity, issue
bundle-branch block, angina, cardiac and further reduction of likelihood of recurrence six-month certificate initially and then annual
arrest, coronary artery bypass grafting, improbable certificate
coronary angioplasty Sudden loss of R, L – If excess likelihood of recurrence is low.*
capability, exercise limitation. Problems Restricted to:
of managing repeat cardiac event at – no lone working or solo watchkeeping; and
sea – operations in near coastal waters, unless
working on vessel with ship’s doctor
Issue six-month certificate initially and then
annual certificate
R, L – If likelihood of recurrence is moderate* and
asymptomatic. Able to meet the physical require-
ments or their normal and emergency duties:
– no lone working or watchkeeping/ lookout; and
– operating within one hour of port, unless
working on vessel with ship’s doctor
Case-by-case assessment to determine
restrictions
Annual review
I44–49 Cardiac arrhythmias and conduc- T – Until investigated, treated and adequacy of L – Surveillance needed at shorter intervals and Surveillance not needed or needed at intervals
tion defects (including those with treatment confirmed no impairing symptoms present and very low* of more than two years; no impairing symptoms
pacemakers and implanted cardio- P – If disabling symptoms present or excess excess likelihood of impairment from recurrence, present; and very low* likelihood of impairment
verter defibrillators (ICD)) Likelihood of likelihood of impairment from recurrence, including based on specialist report from recurrence, based on specialist report
impairment from recurrence, sudden ICD implant R – Restrictions on solo duties or for distant
loss of capability, exercise limitation. waters if low* likelihood of acute impairment from
Pacemaker/ICD activity may be affected recurrence or foreseeable requirement for access
by strong electric fields to specialist care
Surveillance and treatment regime to be specified.
If pacemaker fitted, duration of certificate to
coincide with pacemaker surveillance

2018 Revision 1 37
 ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

I61–69 Ischaemic cerebrovascular disease T – Until treated and any residual impairment R, L – Case-by-case assessment of fitness Not applicable
G46 (stroke or transient ischaemic attack) stabilized and for three months after event for duties; exclude from lone watchkeeping.
Increased likelihood of recurrence, P – If residual symptoms interfere with duties or Assessment should include likelihood of future
sudden loss of capability, mobility there is significant excess likelihood of recurrence cardiac events. General standards of physical
limitation. Liable to develop other fitness should be met (Appendix C).
circulatory disease causing sudden loss Annual assessment
of capability
I73 Arterial-claudication Likelihood T – Until assessed R, L – Consider restriction to non-watchkeeping Not applicable
of other circulatory disease causing P – If incapable of performing duties duties in coastal waters, provided symptoms are
sudden loss of capability. Limits to minor and do not impair essential duties or if they
exercise capacity are resolved by surgery or other treatment and
general standard of fitness can be met (Appendix
C). Assess likelihood of future cardiac events
(follow criteria in I20–25).
Review at least annually
I83 Varicose veins Possibility of bleeding if T – Until treated if impairing symptoms. Post- Not applicable No impairing symptoms or complications
injured, skin changes and ulceration surgery for up to one month
I80.2–3 Deep vein thrombosis/pulmonary T – Until investigated and treated and normally R, L – May be considered fit for work with a Full recovery with no anticoagulant use
embolus Likelihood of recurrence while on short-term anticoagulants low liability for injury in national coastal waters,
and of serious pulmonary embolus P – Consider if recurrent events or on permanent once stabilized on anticoagulants with regular
Likelihood of bleeding from anticoagu- anticoagulants monitoring of level of coagulation
lant treatment

Appendix E
I00–99 Other heart disease, e.g. cardio-my- T – Until investigated, treated and adequacy of Case-by-case assessment, based on specialist Case-by-case assessment, very low* likelihood of
Not listed opathy, pericarditis, heart failure treatment confirmed reports recurrence
separately Likelihood of recurrence, sudden loss of P – If impairing symptoms or likelihood of impair-
capability, exercise limitation ment from recurrence

2018 Revision 1 38
 Guidelines on the medical examinations of seafarers
ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

J00–99 Respiratory system

J02–04 Nose, throat and sinus conditions T – Until resolved Case-by-case assessment When treatment complete, if no factors predis-
J30–39 Impairing for individual. May recur. P – If impairing and recurrent posing to recurrence
Transmission of infection to food/other
crew in some conditions
J40–44 Chronic bronchitis and/or emphy- T – If acute episode R, L – Case-by-case assessment Not applicable
sema Reduced exercise tolerance and P – If repeated severe recurrences or if general More stringency for distant water duties. Consider
impairing symptoms fitness standards cannot be met or if impairing fitness for emergencies and ability to meet gen-
shortness of breath eral standards of physical fitness (Appendix C)
Annual review
J45–46 Asthma (detailed assessment with T – Until episode resolved, cause investigated R, L – Near coastal waters only or on ship with Under age 20: If history of mild or moderate**
information from specialist in all new (including any occupational link) and effective doctor if history of moderate** adult asthma, childhood asthma, but with no hospital ad-
entrants) Unpredictable episodes of treatment regime in place with good control with inhalers and no episodes missions or oral steroid treatment in last three
severe breathlessness In person under age 20 with hospital admission or requiring hospital admission or oral steroid use in years and no requirements for continuing regular
oral steroid use in last three years last two years, or history of mild or exercise-in- treatment
duced asthma that requires regular treatment Over age 20: If history of mild** or exercise-in-
P – If foreseeable likelihood of rapid life-threat-
ening asthma attack while at sea or history of duced** asthma and no requirements for
uncontrolled asthma, i.e. history of multiple hospital continuing regular treatment
admissions
J93 Pneumothorax (spontaneous or T – Normally for 12 months after initial episode or R – Duties in harbour areas only once recovered Normally 12 months after initial episode or shorter
traumatic) Acute impairment from shorter duration as advised by specialist duration as advised by specialist
recurrence P – After recurrent episodes unless pleurectomy or Post surgery – based on advice of treating
pleurodesis performed specialist
K00–99 Digestive system
K01–06 Oral health Acute pain from toothache. T – If visual evidence of untreated dental defects or R – Limited to near coastal waters, if criteria for If teeth and gums (gums alone of edentulous and
Recurrent mouth and gum infections oral disease full fitness not met, and type of operation will with well-fitting dentures in good repair) appear
P – If excess likelihood of dental emergency allow for access to dental care without safety-crit- to be good. No complex prosthesis; or if dental
remains after treatment completed or seafarer ical manning issues for vessel check in last year, with follow-up completed and
non-compliant with dental recommendations no problems since

K25–28 Peptic ulcer Recurrence with pain, T – Until healing or cure by surgery or by control of R – Consider case-by-case assessment for earlier When cured and on normal diet for three months
bleeding or perforation helicobacter and on normal diet for three months return to near coastal duties
P – If ulcer persists despite surgery and medication

2018 Revision 1 39
 ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

K40–41 Hernias – Inguinal and femoral T – Until surgically investigated to confirm no likeli- R – Untreated: Consider case-by-case assess- When satisfactorily treated or exceptionally when
Likelihood of strangulation hood of strangulation and, if required, treated ment for near coastal waters surgeon reports that there is no likelihood of
strangulation
K42–43 Hernias – Umbilical, ventral Case-by-case assessment depending on severity of Case-by-case assessment depending on severity Case-by-case assessment depending on severity
Instability of abdominal wall on bending symptoms or impairment. Consider implications of of symptoms or impairment. Consider implications of symptoms or impairment. Consider implications
and lifting regular heavy whole-body physical effort of regular heavy whole-body physical effort of regular heavy whole-body physical effort
K44 Hernias – Diaphragmatic (hiatus) Case-by-case assessment based on severity of Case-by-case assessment based on severity of Case-by-case assessment based on severity of
Reflux of stomach contents and acid symptoms when lying down and on any sleep symptoms when lying down and on any sleep symptoms when lying down and on any sleep
causing heartburn, etc. disturbance caused by them disturbance caused by them disturbance caused by them
K50, 51, Non-infectious enteritis, colitis, T – Until investigated and treated R – Does not meet the requirements for Case-by-case specialist assessment. Fully con-
57, 58, 90 Crohn’s disease, diverticulitis, etc. P – If severe or recurrent unrestricted certificate but rapidly developing trolled with low likelihood of recurrence
Impairment and pain recurrence unlikely: near coastal duties
K60 I84 Anal conditions: Piles (haemor- T – If piles prolapsed, bleeding repeatedly or Case-by-case assessment of untreated cases for When satisfactorily treated
rhoids), fissures, fistulae Likelihood causing symptoms; if fissure or fistula painful, near coastal duties
of episode causing pain and limiting infected, bleeding repeatedly or causing faecal
activity incontinence
P – Consider if not treatable or recurrent
K70, 72 Cirrhosis of liver Liver failure. Bleeding T – Until fully investigated R, L – Case-by-case specialist assessment Not applicable
oesophageal varices P – If severe or complicated by ascites or oesoph-
ageal varices
K80–83 Biliary tract disease Biliary colic from T – Biliary colic until definitely treated R, L – Case-by-case specialist assessment. Does Case-by-case specialist assessment. Very low
gallstones, jaundice, liver failure P – Advanced liver disease, recurrent or persistent not meet requirements for unlimited certificate. likelihood of recurrence or worsening in next two
impairing symptoms Sudden onset of biliary colic unlikely years

K85–86 Pancreatitis Likelihood of recurrence T – Until resolved Case-by-case assessment based on specialist Case-by-case assessment based on specialist
P – If recurrent or alcohol related, unless confirmed reports reports, very low likelihood of recurrence
abstention

Appendix E
Y83 Stoma (ileostomy, colostomy) T – Until stabilized R – Case-by-case assessment Case-by-case specialist assessment
Impairment if control is lost – need for P – Poorly controlled
bags, etc. Potential problems during
prolonged emergency

2018 Revision 1 40
 Guidelines on the medical examinations of seafarers
ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

N00–99 Genito-urinary conditions

N00, N17 Acute nephritis Renal failure, P – Until resolved Case-by-case assessment if any residual effects Full recovery with normal kidney function and no
hypertension residual damage
N03–05, Sub-acute or chronic nephritis or T – Until investigated R, L – Case-by-case assessment by specialist, Case-by-case assessment by specialist, based on
N18–19 nephrosis Renal failure, hypertension based on renal function and likelihood of renal function and likelihood of complications
complications
N20–23 Renal or ureteric calculus Pain from T – Until investigated and treated R – Consider if concern about ability to work in Case-by-case assessment by specialist with
renal colic P – Recurrent stone formation tropics or under high temperature conditions. normal urine and renal function without
Case-by-case assessment for near coastal duties recurrence
N33, N40 Prostatic enlargement/urinary T – Until investigated and treated R – Case-by-case assessment for near coastal Successfully treated; low* likelihood of recurrence
obstruction Acute retention of urine P – If not remediable duties

N70–98 Gynaecological conditions – Heavy T – If impairing or investigation needed to deter- R – Case-by-case assessment if condition is likely Fully resolved with low* likelihood of recurrence
vaginal bleeding, severe menstrual mine cause and remedy it to require treatment on voyage or affect working
pain, endometriosis, prolapse of genital capacity
organs or other Impairment from pain
or bleeding
R31, 80, Proteinuria, haematuria, glycosuria T – If initial findings clinically significant L – When repeat surveillance required Very low likelihood of serious underlying condition
81, 82 or other urinary abnormality Indicator of P – Serious and non-remediable underlying cause R, L – When uncertainty about cause but no
kidney or other diseases –e.g. impairment of kidney function immediate problem
Z90.5 Removal of kidney or one non-func- P – Any reduction of function in remaining kidney R – No tropical or other heat exposure. Serving Remaining kidney must be fully functional and
tioning kidney Limits to fluid regulation in new seafarer. Significant dysfunction in re- seafarer with minor dysfunction in remaining not liable to progressive disease, based on renal
under extreme conditions if remaining maining kidney of serving seafarer kidney investigations and specialist report
kidney not fully functional
O00–99 Pregnancy

O00–99 Pregnancy Complications, late limi- T – Late stage of pregnancy and early postnatal R, L – Case-by-case assessment if minor im- Uncomplicated pregnancy with no impairing
tations on mobility. Potential for harm period pairing effects. May consider working until later in effects – normally until 24th week
to mother and child in the event of Abnormality of pregnancy requiring high level of pregnancy on near coastal vessel Decisions to be in accord with national practice
premature delivery at sea surveillance and legislation. Pregnancy should be declared at
an early stage so that national recommendations
on antenatal care and screening can be followed

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 ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)
L00–99 Skin
L00–08 Skin infections Recurrence, transmis- T – Until satisfactorily treated R, L – Based on nature and severity of infection Cured with low likelihood of recurrence
sion to others P – Consider for catering staff with recurrent
problems
L10–99 Other skin diseases, e.g. eczema, T – Until investigated and satisfactorily treated Case-by-case decision Stable, not impairing
dermatitis, psoriasis Recurrence, some- R – As appropriate if aggravated by heat, or
times occupational cause substances at work
M00–99 Musculoskeletal
M10–23 Osteoarthritis, other joint diseases T – Full recovery of function and specialist advice R – Case-by-case assessment based on job Case-by-case assessment. Able to fully meet
and subsequent joint replacement Pain required before return to sea after hip or knee requirements and history of condition. Consider routine and emergency duty requirements with
and mobility limitation affecting normal replacement emergency duties and evacuation from ship. very low likelihood of worsening such that duties
or emergency duties. Possibility of P – For advanced and severe cases Should meet general fitness requirements could not be undertaken
infection or dislocation and limited life (Appendix D)
of replacement joints
M24.4 Recurrent instability of shoulder T – Until satisfactorily treated R – Case-by-case assessment of occasional Treated; very low* likelihood of recurrence
or knee joints Sudden limitation of instability
mobility, with pain
M54.5 Back pain Pain and mobility limitation T – In acute stage Case-by-case assessment Case-by-case assessment
affecting normal or emergency duties. P – If recurrent or incapacitating
Exacerbation of impairment

Appendix E
Y83.4 Z97.1 Limb prosthesis Mobility limitation P – If essential duties cannot be performed R – If routine and emergency duties can be If general fitness requirements are fully met
affecting normal or emergency duties performed but there are limitations on specific (Appendix C). Arrangements for fitting prosthesis
non-essential activities in emergency must be confirmed

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 Guidelines on the medical examinations of seafarers
ICD-10 Condition Incompatible with reliable performance of routine Able to perform some but not all duties or to Able to perform all duties worldwide
(diagnostic (justification for criteria) and emergency duties safely or effectively work in some but not all waters (R) within designated department
codes) – expected to be temporary (T) Increased frequency of surveillance needed (L)
– expected to be permanent (P)

General
R47, F80 Speech disorders P – Incompatible with reliable performance of R – If assistance with communication is needed No impairment to essential speech communication
Limitations to communication ability routine and emergency duties safely or effectively to ensure reliable performance of routine and
emergency duties safely and effectively
Specify assistance
T78 Z88 Allergies (other than allergic dermatitis T – Until fully investigated by specialist Case-by-case assessment of likelihood and se- Where response is impairing rather than
and asthma) Likelihood of recurrence P – If life-threatening response reasonably verity of response, management of the condition life-threatening, and effects can be fully controlled
and increasing severity of response. foreseeable and access to medical care by long-term non-steroidal self-medication or by
Reduced ability to perform duties R – Where response is impairing rather than lifestyle modifications that are practicable at sea
life-threatening, and reasonable adjustments can with no safety-critical adverse effects
be made to reduce likelihood of recurrence
Z94 Transplants – Kidney, heart, lung, T – Until effects of surgery and anti-rejection R, L – Case-by-case assessment, with specialist Not applicable
liver (for prosthetics, i.e. joints, limbs, medication stable advice
lenses, hearing aids, heart valves, P – Case-by-case assessment, with specialist
etc. see condition-specific sections) advice
Possibility of rejection. Side effects of
medication
Classify by Progressive conditions, which T – Until investigated and treated if indicated Case-by-case assessment, with specialist advice. Case-by-case assessment, with specialist advice.
condition are currently within criteria, e.g. P – Consider at pre-sea medical if likely to prevent Such conditions are acceptable if harmful pro- Such conditions are acceptable if harmful pro-
Huntington’s chorea (including family completion or limit scope of training gression before next medical is judged unlikely gression before next medical is judged unlikely
history) and keratoconus
Classify by Conditions not specifically listed T – Until investigation and treated if indicated Use analogy with related conditions as a guide. Use analogy with related conditions as a guide.
condition P – If permanently impairing Consider likelihood of sudden incapacity, Consider excess likelihood of sudden incapacity,
recurrence or progression and limitations on of recurrence or progression and limitations on
performing normal and emergency duties. If in performing normal and emergency duties. If in
doubt, obtain advice or consider restriction and doubt, obtain advice or consider restriction and
referral to referee referral to referee

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 Notes:
* Recurrence rates: Where the terms very low, low and moderate are used for the excess likelihood of a recurrence. These are essentially clinical judgements but, for some conditions, quantitative evidence on the likelihood of recurrence is available. Where
this is available, e.g. for seizure and cardiac events, it may indicate the need for additional investigations to determine an individual’s excess likelihood of a recurrence.
Quantitative recurrence levels approximate to:
– Very low: recurrence rate less than 2 per cent per year;
– Low: recurrence rate 2–5 per cent per year;
– Moderate: recurrence rate 5–20 per cent per year.
** Asthma severity definitions:
Childhood asthma:
– Mild: Onset age > ten, few or no hospitalizations, normal activities between episodes, controlled by inhaler therapy alone, remission by age 16, normal lung function.
– Moderate: Few hospitalizations, frequent use of reliever inhaler between episodes, interference with normal exercise activity, remission by age 16, normal lung function.
– Severe: Frequent episodes requiring treatment to be made more intensive, regular hospitalization, frequent oral or IV steroid use, lost schooling, abnormal lung function.
Adult asthma:
Asthma may persist from childhood or start over the age of 16. There is a wide range of intrinsic and external causes for asthma developing in adult life. In late-entry recruits with a history of adult onset asthma, the role of specific allergens, including those
causing occupational asthma, should be investigated. Less specific inducers such as cold, exercise and respiratory infection also need to be considered. All can affect fitness for work at sea.
– Mild intermittent asthma: Infrequent episodes of mild wheezing occurring less than once every two weeks, readily and rapidly relieved by beta agonist inhaler.
– Mild asthma: Frequent episodes of wheezing requiring use of beta agonist inhaler or the introduction of a corticosteroid inhaler. Taking regular inhaled steroids (or steroid/long-acting beta agonists) may effectively eliminate symptoms and the need for use of
beta agonist treatment.
– Exercise-induced asthma: Episodes of wheezing and breathlessness provoked by exertion, especially in the cold. Episodes may be effectively treated by inhaled steroids (or steroid/long-acting beta agonist) or other oral medication.
– Moderate asthma: Frequent episodes of wheezing despite regular use of inhaled steroid (or steroid/long acting beta agonist) treatment requiring continued use of frequent beta agonist inhaler treatment, or the addition of other medication, occasional
requirement for oral steroids.
– Severe asthma: Frequent episodes of wheezing and breathlessness, frequent hospitalization, frequent use of oral steroid treatment.

Appendix E
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