ANNEX C

MARITIME AND PORT AUTHORITY OF SINGAPORE

SEAFARER'S MEDICAL CERTIFICATE

MPA
I G POR

his certficate is issued by the undersigned recognized medical practitioner to the named seafarer on behalf of the
aritime and Port Authority ofSingapore and meets both the requirements of the International Convention on Standards
of Trainings. Certification and Watchkeeping for Seafarers, 1978, as amended (STCw Convention) and the Maritime
Labour Convention, 2006.

Seafarer's Name:(Last, first, middle) Gender:

RIAN DAUD SADEWA Male/Femete
Date of Birth: (Day/month/year) Nationality: Place of Birth:
10/09/1994 INDONESIAN BOYOLALI

Declaration of the recognized medical practitioner

Yes No
1 ldentification documents were checked at the point of examination?
2 Hearing meets the standards in STCW Code Section A-l/9?
3 Unaided hearing satisfactory?
4 Visual acuity meets the standards in STCW Code Section A-/9?
5 Colour vision meets the standards in STCW Code Section A-/9?

Date of last colour vision test: 09 03 / 2021

6 Fitfor look-out duty? V

s the seafarer free from any medical condition likely to be aggravated by service at sea or
7 to render the seafarer unfit for such service or endanger the life of person onboard?

8 No limitations or restrictions on fitness?

If "no" specify limitations or restrictions

09 03 2021
9 Date of examination: (day/month/year)
Expiry of certificate: (day/month/year)
10 Maximum two years fron date of examination unless the seafarer is under the age-of18- 09 03 2023
KINPO

JL. ANJASMORO RAYA NO.38-A7 KARANGAYU,SEMARANG BARAT

MARCH 09, 2021
Date thorised Medical Practitioner's Official stamp
(name, llcence number, address etc)

cetificate and of the right to a review.

I have been inforpedof the content of the

Signatureof Seafarer
delete as approprialo
Page 1 of 1
SEFARER MEDHCAL CERTInICATE- Merch 2020
Part B-Result of medical examinations
Eyesight
Use of glasses or contact lenses

No
Yes Type Purpose

Visual Acuity

Unaided Aided
Right eye Left eye Binocular Right eye Left eye | Binocular
Distant 6/5 Distant
20/20 Near
Near
Visual fields

Normal Defective
Right eye
|Left eye
Colour Vision (please tick)

Not tested Normal Doubtful Defective

Hearing
Pure tone and audiometry (threshold values in dB)_
500 Hz 1,000 Hz 2,000 Hz 3,000 Hz
25 25 15 25
Right ear
20
Left ear 25 15 15
Speech and whisper test (metres)

Normal Whisper
Right ear V

Left ear V

Clinical Findings
99
Height (Cm 180
Weight (kg)
Pulse rate_ (per minute)_ 76 Rhythm REGULAR
110 Diastolic (mm Hg)|L 80
Blood Pressure Systolic (mm Hgg]
Urinalysis: Glucose NEGATIVE Protein:NEGATIVE Blood: NEGATIVE

Normal Abnormal
V
Head
Sinus, nose, throat
Mouth/teeth
Page 3 of 5
BCORD OF EDICAL ELMMANONS OF BEWANER-Mereh 2020
37. Have you ever been declared unfit for sea duty?
38. Has your medical certificate even been restricted or revoked?
39. Are you awarethat you have any medical problems, diseases orillnesses?
40. Doyoufeel healthy and fit toperformtheduties ofyourdesignated position/occupation?
41. Are you allergic to any medication?
42. Are you using any non-prescription or prescription medication?
| f you answer "yes", please list the medications taken, the purpose(s) and the dosage

I hereby declare that the personaldeclaration above is a true statement to the best of my knowledge.
INIK
MARCH 09,2021 d SantKriktiahi. 2 k
Date Signature onseafarer Namend Signature of Witness
Seafarer Medical
previous medical records (including my last
T hereby authorize thee release of all my
institutions and public authorities to Dr.
Certificate) from any health professional, health
Dr.SAID HUSIN
DOSE
MARCH 09, 2021 santi krs S.PK
Signature of Seafarer Name and Sigare of Witness
Date

Page 2 of 5
BEAFAREd-rch 2020
MEDICAL ELAATIOMS or
SCORD OF
 ANNEX B3
MARITIME AND PORT AUTHORITY OF SINGAPORE
SHIPPING DIVISION

RECORD OF MEDICAL EXAMINATIONS OF SEAFARER

MP A

Part A- to be completed by the Seafarer who is responsible for answering each question accurately.
Seafarer's Name :(Last, first, midde) Gender:
(BLOCK CAPITALS) RIAN DAUD SADEWA Male/Female"
Date of Birth: day/month/year Place of Birth: Nationality: INDONESIAN
10/09/1994 BOYOLALI
Type of ID documents RIC No. Dept: Deck(Enginey Catering/ others Type of ship:
Passport No.: B 8039111 Rank ENGINEERR

Routine and emergency duties: Trading area: e.g coastal

Home Address:
world wide
BANGUN HARJO RT 05 RW 03, BOYOLALI JAWA TENGAH

Seafarer's Declarations (please tick

Have you ever had any of the following conditions?

Yes No Yes No
1.Eye/vision problem v18. Sleep problem
| 2. High blood pressure 19. Do you smoke, use alcohol or drugs?
3. Heartvasculardisease v 20. Operation/surgery
4. Heart Surgery v 21. Epilesy/seizures
5. Varicose veins/piles 22. Dizziness/fainting
6 . Asthma/bronchitis V 23. Loss of consciousness
7. Blood disorder v24. Psychiatric problems
8. Diabetes v25. Depression
9. Thyroid problem 26. Attempted suicide
10. Digestive disorder v27. Loss of memory
11. Kidney problem 28. Balance problem
12. Skin Problem v 29. Severe headaches
30. Ear(hearing, tinnitus/nose/throat problem
13. Allergies
14. Infectious/contagious diseases v 31. Restricted mobility
15. Hernia 32. Back or joint problem

16. Genital disorder 33. Amputation

17. Pregnancy 34. Fracture/dislocations
details:
| If you answer "yes" to any of the above questions, please provide

Additional questions Yes No

35. Have you ever been signed off as sick or repatriated froma ship?
36. Have you ever been hospitalized?
Page 1 of 5
ECORD OF MEDICAL BINATIOS OF SEAFARERS-Meroh 2020
 Ears (general)
Tympanic membrane
Eyes
Ophthaimoscopy
Pupils
Eye movement
Lungs and chest
Breast examination
Heart
Skin V

Varicose Vein
Vascular (inc. pedal pulse)
Abdomen and visoera
Hemia
Anus (not rectal exam)
G-U system
Upper and lower extremities
Spine (Cls, T/S, L/S)
Neurologic (full/brief
Psychiatric
General appearance

Chest Xray

Not performed vPerformed on (day/month/year):....MARCH09,2021..

NORMAL
Results: . . . .

Other diagnostic test(s) and result(s):

Test ****
Results:..
limitations.
Medical practitioner's comments and assessment of fitness, with reasons for any

Assessment of fitness for service at sea (please tick)

cinical examination and diagnostic test
On the basis of the seafarer's personal declaration, my
results recorded above, I declare the seafarer medically:

Fit for look out duty Unfit for lookout duty

Visual aid required Visual aid not required

Deck Engine Catering Other

Service Service Service Service
Fit
Unfit
Page 4 of 5
RECORD OF MEDICAL ENATOS Or BEAAREU- Merah 2020
 RAHB INDOSEHAT 2003 Approved By
CLINIC& MEDICAL CHECK-UP

MEDICAL EXAMINATION REPORT

COMPANY PT.LHYK MARINE PTE. LTD
MCU NO. 5993/MCUIS_SMG/LM/II/21
NAME MR RIAN DAUD SADEWA
SEX Male
PLACE& DATE OF BIRTH NATIONALITY INDONESIA
BOYOLALI / SEPTEMBER 10, 1994
MAILING ADDRESS OF EXAMINEE
BANGUN HARJO RT 05 RW 03, BOYOLALI JAWA TENGAH
DUTY :ENGINEER PASSPORT B8039111

MEDICAL HISTORY PHISICAL EXAMINME

(EXAMINEE PERSONAL DECLARATION)
HEIGHT| WEIGHT| BLOOD PULSE RESPIRATORY
Yes/No RATE
1. ALCOHOL HISTORRY No PRESSURE REGULAR
180 99 1 10/80
ALLERGIC HISTORY No
ABNORMAL HEARTBEAT No Cm kg mmHg 76 X/min 17X min

4 BLOOD IN URINNE No COLOR VISION

VISION WITHOUT| WITH
5. CANCER NO
(IsIHARA'S METHOD)
CHEST PAIN No
7. COLOR BLINDNESS No COLOR BLINDNESS
8. DIZZINESS No Right Eye 6/6
9 DIABETES No Left Eye 6/5
Both Eye 6/5 NORMAL
10. DIPTHERIA NO
11. EAR DITURBANCES No
GENERAL APPEARANCE
12. EPILEPSY No
13. FREQUENT HEADACHE No
LOOKING HEALTHY
14. FEAR OF HEIGHTS No
15.GALL BLADDER DISEASE No HEARING
DENTAL EXAMINATION
16HAYFEVER/OTHER ALLERGYNo
17. HEADACHE/MIGRAINE No Normal
18. HEART DISEASE No 8765432 1123 45678
Right Ear Yes
19. HIGH BLOOD PRESSURE No 87654 3 2 11 123 45678 Yes
20. JAUNDICE OR HEPATITIS No Filling O Caries Root Rest| Leaft Ear
x Missing V Prothesa
21. KIDNEY DISEASE No
22. LIVER DISEASE No
23. LUNG DISTURBANCES No NORMAL NORMAL
1. EYES Yes 11. ABDOMEN Yes
24. MALARIA No 12. UROGENITAL SYSTEM Yes
2. EARS Yes
25. MEASLES No 13. UPPER EXTREMITIES Yes
3 NOSE Yes
26. NARCOTIC HISTORY No 14. LOWER EXTREMITIES Yes
27. NERVE DISTUBANCES No 4. MOUTH Yes
5. THROAT Yes 15. BACK ABNORMALITY Yes
28.PEPTIC ULSER No Yes
6. NECK Yes 16. HERNIA
29 RHEUMATIC FEVER No 17. CENTRAL NERVOUS SYSTEM Yes
7. THROIDYes
30.REUMATISM No Yes
8. LYMP NODE Yes 18. SKIN & NAILS
31.SERIOUS CHEST PAIN No
9 LUNGS Yes 19. SPEECH Yes
32. SINUS TROUBLE
10. HEARTS Yes 20. OTHERS Yes
33.SURGICAL OPERATION No
34.TUMOR No
35.TUBERCULOSIS No If abnormal , give details
36.VENERAL DISEASE No
37.VARICOSE VEINS N NIL

JI. Anjasmoro Raya No. 38-A/7 Karangayu,

Semarang Barat Telp. (024) 7617189
Email: [email protected]
 RAHB INDOSEHAT 2003
CLINIC& MEDICAL CHECK-UP Approved By
30 9001:2016 n

REPORT LABORATORY RESULTT

Company : PT.LHYK MARINE PTE. LTD
Name MR. RIAN DAUD SADEWA Sex : Male
MCU No.
Date Examination
:5993/MCUIS SMG/LM/III/21 No. MR:271
MARCH 09, 2021 Age 26 Years Old|

Laboratory Test Reference Ranges Result

HEMATOLOGY
Hemoglobin 13.0 16.0 gr / dl 15,1
White Blood Cell Count 5.0-10.0 ul 5,23
Red Blood Cell Count 4.5-5.5 mlln/ul 4,12
Haematokrit / PCV 37 48 40,2
ESR 15 mm/ hour 8
DIFFERENTIAL COUN
Eosinophil -3 %
Basophil 0-1
Stab 2-6 4

Segment 50 70 65
Limphocyte 20 40 23
Monocyt 2- 8 % 6
Trombosit 150-440 thsn / ul 212
MCV 82 93 97
MCH 27-31 Pg/cell 32
MCHC 32 36 g/g 33

BLOOD CHEMISTRY
Random Glucose 70 1800 mg//dl 112

JI. Anjasmoro Raya No. 38-A/7 Karangayu,

Semarang Barat Telp. (024) 7617189

Email: [email protected]
 RAHB INDOSEHAT 2003 Approved By
CLINIC& MEDICAL CHECK-UP
O O1:2016

REPORT LABORATORY RESULT

PT.LHYK MARINE PTE. LTD

Company Sex : Male
Name : MR RIAN DAUD SADEWA
No. MR :271
MCU No. 5993/MCUISSMG/LM/II/21
MARCH 09, 2021 Age : 26 Years Old
Date Examination

Reference Ranges Result

Laboratory Test

URINALYSIS
Macroscopic 1010
Spesific Gravity 1,000-1,030
Negative Negative
Albumin
Negative Negative
Glucose
6,0
PH
Microscopic
Sediment Positive
Epithels/ hpf Positive
0-5 0-2
WBC/hpf - 5 0-3
RBC/hpf Negative Negative
Cast
Negative Negative
Crystal Negative
Bacteria Negative
Negative Negative
Others

SEROLOGY / IMMUNOLOGY

Non Reactive Non Reactive

VDRL Non Reactive
Non Reactive
HIV

ANK
RDOSE
dr.SantKristani, Sp.PK
PatologiCimic
EC

JI. Anjasmoro Raya No. 38-A/7 Karangayu,

Semarang Barat Telp. (024) 7617189
Email: [email protected]
 RAHBINDOSEHAT 2003 Approved By
CLINIC& MEDICAL CHECK-UUP

PATIENT DATA

COMPANY LHYK MARINE PTE LID

NAME RIAN DAUDSADEWA
AGE 26
NOMR 5993

Tone Audiogram
LEFT FF1
RIGHT FFI

S00 1000 2000 4000 6000 8000

250 500 1000 2000 4000 6000 8000 250
-10
-10

10
10

20

0
40
40
50
50

60

70
80
80
90
90
100
100
110
110
120
120
Left
Right
Ear Left Ear Air Conductio Ear
Right Ear Air Conduction
(dB) (dB)
250 S00 1000 2000 4000 6000 8000
250 500 1000 2000 4000 6000 8000
25 2525 15 255030 22.5 25 25 1515 20 40 35 18,75
Left
Right
Ear Left Ear Bone Conduction Ear
Right Ear Bome Conduction
(dB) (dB)
250 500 1000 2000 4000 6000 8000
250 500 1000 2000 4000 6000 8000

Right Ear Vbm, turan d FreFuenr ooo H KLINA HDO SE

LetEar bn
ConclusionDbn

Examin Rsan
hndac paparan b sng dr. Desy Irni, SpTHT-KL
Satan Tunga d tempa brcin
paa a t peuncdung

JI. Anjasmoro Raya No. 38-A/7 Karangayu,

Semarang Bara Telp. (024) 7617189
Email: [email protected]
 RAHB INDOSEHAT 2003
CUNIC& MEDICAL CHECK-UP Approved By

190 O01:2016

MCU NO: 5993/MCUIS_SMG/LM/I/21

DECLARATION OF ANTI HIV TEST RESULT

Name MR. RIAN DAUD SADEWA

Age 26 Years Old

Adress BANGUN HARJO RT 05 RW 03, BOYOLALI JAWA TENGAH

PT.LHYK MARINE PTE. LTD

Company

Is Non Reactive

This is to certify that the test is correct and true.

SEMARANG, MARCH 09, 2021

NIK

SAD HUSIN
Medical REview Officer

JI. Anjasmoro Raya No. 38-A/7 Karangayu,

Semarang Barat Telp. (024) 7617189
Email [email protected]
 RAHB INDOSEHAT 2003
CLINIC& MEDICAL CHECK-UP Approved By

O O1:204

CERTIFICATION
DRUGS AND ALCOHOL

MCU. No 5993/MCUIS_SMG/LM/II/21
Company :PT.LHYK MARINE PTE. LTD
Date MARCH 09, 2021

This is to certify that

Name MR. RIAN DAUD SADEWA

Sex Male
Place/Date Of Birth BOYOLALI/ SEPTEMBER 10, 1994
Age :26 Years Oid
Rank ENGINEER

Was examed for the presence of the following drugs and alcohol in the urine using the
competitive immonoassay / chomatographic Absorbent method and was found

Amphetamine Negative Coccaine Negative

Methamphetamine Negative Marijuana/Cannabinoids Negative
Opiate/Morphine Negative Barbiturate Negative
Phencyclidine Negative Benzodiazepine Negative
Codeine Negative Alcohol Negative

Note
NVE Not Examine

SEMARANGMARCH 09, 2021

drlSAIDAUSIN
MedtealReview Officer

JI. Anjasmoro Raya No. 38-A/7 Karangayu,

Semarang Barat Telp. (024) 7617189
Email: [email protected]
 RAHB INDOSEHAT 2003
CUNIC& MEDICAL CHECK-UP Approved By

LABORATORY FINDING
BLOOD TEST URINALYSYS
HEMATOLOGY SPECIFIC GRAFITY 1010
PROTEIN Negative
HB 15,1 gr/d GLUCOSE Negative
WBC :5,23 Thsn/ ul MCH 32 PH 6,0
ESR 8 mm/hour MCHC: 33
PLATELET :212 thsn/ul PCV 40,2
DIFF COUNT: 0/2/4/65/23/6
MICROSCOPIC
BLOOD CHEMISTRY WBC 0-2 /hpt
RBC 0-3 /hpt
CAST :Negative
GDS :112 mg/dl CRYSTALS:Negative
BACTERIA:Negative

SEROLOGY/IMUNOLOGI
HIV :NonReactive
VDRL :NonReactive
No. 271
CHESTX-RAY Report NORMAL

OTHER DIAGNOSTIC TEST

ECG :NORMAL

CLINICAL EVALUATION
COMMENT ON MEDICAL HISTORY AND
The abovenamed person physically:
FIT
OFIT WITH MEDICINE
ASSIGNMENT
HAS MAYOR PHYSICAL DEFECT; FIT WITH RESTRICTION OF SELECTED
OUNFIT
For duties on board ship FIT TO BE DUTY ON BOARD
Doctor's Advice

HEALTH CERTIFICATE
No.:5993/MCUIS_SMG/LM/I21

GIVEN TO:
THATA MEDICAL EXAMINATION WAS
THIS TO CERTIFICATE AGE 26 YEARS
MR. RIAN DAUD SADEWA

DUTY AS: ENGINEER

HE IS FOUND TO BE FIT FOR
ISSUED AT SEMARANG
NIK
ntphysician
2021
DATE OF EXAMINATION, MARCH 09, 2023
EXPIRATION OF VALIDITY, MARCH 09,

dr.SADAUSIN

JI. Anjasmoro Raya No. 38-A/7 Karangayu,

Semarang Barat Telp. (024) 7617189
Email: [email protected]
 Without restrictions With restrictions
Description of restrictions (e.g. specific position, type of ship, trading area etc.)

I K
NDOSE
INO

MARCH 09, 2021 SAIDUsIN JL. ANJASMORO RAYA No.38-A7 KARANGAYU,SEMARANG BARAT
Date MART edica Practitioner
E C of Medical Practitioner's name, licence number, address

************

RECORD OF MEDICAL ELAMNATNOMB OF SEAFARERS-Merch 2020 Page 5 of 5