MEDICAL EXAMINATION for EMPLOYMENT

INSTRUCTIONS TO THE CREW MEMBER

Dear Crew Member,

You are required to have a valid Medical Examination before joining your Crystal Cruises River ship. Take time to
read this instruction before going for your medical examination.

1. Take the Medical Examination Report to the doctor or clinic that has been recommended by your agent or Crystal
Cruises Manning AS. Alternatively, visit your licensed private physician only if agreed to with Crystal Cruises
Manning AS.

2. Attach a passport size photo to page 5, Medical Certificate.

3. Fill in the self declaration on page 6 and 7 and sign it.

4. Fill in the self declaration “Back and Spine” on page 10 and sign it.

5. The doctor shall fill in all other information on pages 5, 6, 8 and 9.

6. When all of the test results are determined, the doctor shall complete page 5, stating whether you do/do not
meet the medical requirements. The doctor shall also sign page 5 and affix his/her official stamp.

7. Once all of the pages (5 through 10) are completed, you need to forward all 6 pages and all lab tests to Crystal
River Cruises Manning Ltd. before you will be permitted to travel to your ship. You can forward them as follows:

- Scan / email to [email protected]

8. Crystal River Cruises Manning Ltd. will contact you with your travel instructions once our Company Medical Advisor
has approved your medical examination. Your medical examination is not valid till we have this approval from our
Medical Advisor.

9. Bring your copy of the Medical Examination with you to the ship.

Thank you for carefully following these instructions. By doing so, you will help us to get you onboard your
ship in the most timely manner, with your medical documentation in order. If you have any questions, do not
hesitate to contact your Personnel Consultant at Crystal Cruises Manning.

Kind regards,
Crystal River Cruises Manning Ltd.

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January 2019
 MEDICAL EXAMINATION for EMPLOYMENT

INSTRUCTIONS TO THE DOCTOR

Dear Doctor,

The seafarer you are about to examine is seeking work onboard a river cruise ship operated by
Crystal Cruises. Attached you will find a Medical Certificate and a Medical Examination Report that
you need to complete. Please note the following important details:

Medical Certificate
• The medical certificate is valid for a period of two years.
• Ensure that all information for the seafarer is completely filled in, including the ID
(Passport and/or Discharge Book) number on page 5.
• Ensure that the attached photograph is the person to be examined. Place your official
stamp partially on the photograph and the document.
• Upon completion of the medical examination, be sure to complete all details about your
name, clinic or hospital, and address. Affix your stamp to the Medical Certificate (page 6).

Medical Examination Report

• Ensure that the seafarer has completed all voluntary information correctly (pages 6, 7
and 10).
• Verify the Personal Medical History information carefully with them. You need to sign as a
witness on page 7.
• Please note that no vaccinations are required or authorized, unless specifically requested
by the Employer. See page 6.
• Conduct the complete Medical Examination and Summary on pages 8 and 9.
• We ask you to specifically check the seafarer’s back and spine for signs of injury or
weakness. Any skeletal weaknesses or injuries will disqualify the seafarer from
employment with us.
• We ask you to be thorough and honest in your evaluation of the seafarer.
• It is very important that all test results are determined before the Medical Certificate is
completed. Please attach the analysis reports to the Medical Examination Report.
• Carefully read the attached Medical Guidelines for Hiring Crystal Shipboard
Personnel.

Thank you for your kind attention to this important medical examination for employment on Crystal
River Cruises.

Sincerely,

Ingrid Kihle
Director
Crystal River Cruises Manning Ltd.
Europa Center – John Lopez Street – FRN1400 Floriana – Malta

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January 2019
 MEDICAL GUIDELINES FOR HIRING CRYSTAL RIVER SHIPBOARD
PERSONNEL
The employment physical examination should establish that the applicant does not have any mental or
physical disability or disease that interferes with his or her daily work or may in any way endanger the
health of other persons onboard. It should also ensure that the applicant’s visual acuity, color vision and
hearing fulfill the international regulation requirements for his or her type of work onboard.

GENERAL DISQUALIFYING CONDITIONS (NOT FIT FOR SEAGOING EMPLOYMENT)

• Any mental, physical or medical condition that may interfere with the ability to function
effectively in daily work onboard, in any emergency, or in any drill.
• Conditions that may endanger life or health of others onboard.
• Visual ability or hearing poorer than the international regulation requirements. (See page below)
• Conditions that require regular medical follow-up or medication.*
• Medical conditions that harbor risk of flare-ups or complications necessitating emergency
evacuation from the ship.

SPECIFIC DISQUALIFYING CONDITIONS (NOT FIT FOR SEAGOING EMPLOYMENT)

1. Communicable diseases, including venereal disease
• Venereal disease until adequately treated
• Active or incompletely treated tuberculosis
• Persons with radiological signs of pulmonary tuberculosis where previous treatment history
cannot be verified.

2. Malignant neoplastic disease

3. Endocrine disease
• Diabetes mellitus Type I insulin dependent
• Diabetes mellitus Type II unstable *

4. Mental and psychological diseases

• Psychoses and severe depression requiring active psychotic drugs
• Neurotic disorders needing treatment and requiring the use of psychotropic drugs
• Behavioral disturbances, obvious adaptation difficulties
• Enuresis
• Alcoholism
• Drug addiction or abuse
• History of illicit drug use
• Any regular use of psychotropic drugs
• History of psychosis

5. Neurological disease
• Symptomatic neurologic disorders
• Epilepsy
• Severe migraine headaches
• Neuralgias

Page 3
January 2019
6. Cardiac disease
• Symptomatic or functionally significant heart disease
• Peripheral vascular disease
• Hypertension (individual assessment)*
• Conditions requiring continuous anticoagulant therapy

7. Respiratory disease
• Chronic bronchial conditions
• Asthma requiring treatment

8. GI disease
• Disease of the teeth and gums until adequately treated
• Recurring dyspepsia with or without ulcer
• Symptom-giving gallstones
• Chronic diseases of liver or pancreas
• Chronic enteritis or colitis
• Hernia (untreated or unsuccessfully treated).

9. GU disease
• Present calculi (stones) of urinary tract
• Chronic nephritis or nephrosis
• Prostatitis

10. Gynecological disease and conditions

• Recurring salpingitis
• Irregular menses (periods) with heavy blood loss
• Pregnancy

11. Dermatological disease

• Contagious skin diseases until adequately treated
• Severe skin diseases
• Allergies to substances commonly onboard (e.g. metals, petroleum products, detergents)

12. Musculoskeletal disease

• Recurring or chronic back pain with significant disability
• All musculoskeletal diseases, congenital malformations and sequelae after injuries which will
interfere with the ability to function effectively in an emergency or drill.

13. Long term medications

Person needing long term medication for reasons not mentioned above (e.g. transplant recipients). *
* Persons with these conditions might be approved by CCL’s Medical Consultant after his careful
evaluation of the individual’s history, symptoms and your objective findings. Examining physicians
should mark the Medical Certificate “DOES NOT meet physical requirements” and describe the
reason and notify Crystal Cruises Manning AS who will arrange for further evaluation.

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January 2019
 MEDICAL CERTIFICATE

Last Name First and Other Names Position applied for

Date of Birth Sex Nationality ID (Passport/Discharge book) No:

DD MM YYYY
Ship Name

I have evaluated the above-named examinee according to the Crystal River Cruises Manning Ltd. Medical
Guidelines (Based on UK Medical Requirements for Seafarers MSN1765(M), and on the basis of the examinee’s
personal declaration, my clinical examination, and the diagnostic test results obtained, and in consideration of the
essential requirements of the position applied for, in my opinion this employee DOES / DOES NOT meet the
physical requirement for this job.
(circle one)
Restrictions applied: None/……………………………………………………

If unfit state reason

The hearing/sight and colour vision are all satisfactory in capacities where fitness for the work to be performed is
liable to affected by defective colour vision. Furthermore, the above name examinee is not suffering from any
medical condition likely to be aggravated by sea service or to render him/her unfit for such service or to endanger
the health of other persons onboard.

Visual aid required (specify) Yes/No Informed spares necessary Yes/No Fit for lookout duty Yes/No

Signed: Name:

Clinic stamp:

Date: DD MM YYYY

Valid Until: DD MM YYYY

I acknowledge that I have been advised of the content of the medical examination form.

Crew Member’s signature:

A copy of this page should be kept by the examining physician, and a copy sent to the CRCM.
The entire original medical examination form should be given to the seafarer.

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January 2019
 MEDICAL EXAMINATION REPORT - STRICTLY CONFIDENTIAL
This examination must be carried out by an authorized physician. The seafarer must meet the minimum standards set down
by the authorizing body. Reference should also be made to the guidelines included.

Last name First and Other Names

Date of Birth Sex Position/Job Applied For

DD MM YYYY

Home Address Usual Medical Practitioner – Name/Address

Date/result of last medical examination: Date/result of last Employment Physical Exam (if any): DD MM YYYY

EMPLOYMENT PHYSICAL EXAM QUESTIONNAIRE - PERSONAL MEDICAL HISTORY

To be completed by the Crew Member and given to the Examining Physician.

Vaccination status (This section is for information only. No vaccinations are required/authorised as part of this exam)
State date of last vaccination/immunity (if not vaccinated, state N/A next to the item):
Diphtheria: Tetanus: Pertussis: Polio: Hepatitis A:
Typhoid : Hepatitis B: Yellow Fever: MMR: Varicella:

To the best of your knowledge, have any of your family ever suffered from any of the following? Heart conditions/angina,
Blood pressure problems, Stroke/vascular disease, Mental/nervous, disorder, Diabetes, Tuberculosis, Asthma/eczema,
Glaucoma, Epilepsy/fits, Cancer, Anaemia
If yes, please give details:

Are you taking any non-prescription or prescription medications? Yes/No

Please list with dosage, and reason for taking
___________________________________________________________________
Note: failure to list all medications you are currently taking could result in disciplinary action up to termination.
Have you any allergies to medications, or to environmental allergens eg Hay Fever? Yes/No
If yes, please list:____________________________________________________________________________________
Do you smoke? Yes/No Number of cigarettes per day
Do you drink alcohol? Yes/No Number of units per week

Do you feel healthy and fit to perform the duties of your designated position/occupation? Yes/No
Have you ever been declared unfit for sea duty, or had your medical certificate restricted or revoked? Yes/No

Page 6
January 2019
EMPLOYMENT PHYSICAL EXAM QUESTIONNAIRE - PERSONAL MEDICAL HISTORY
To be completed by the Crew Member and given to the Examining Physician.
Have you ever had any medical conditions affecting the systems below? Y N If yes, give details:

Eye or vision problem: Glaucoma, Eye injury, Glasses/ contact lenses

Dental problems
Ear/nose/throat problems: Ear Infections, Hearing Problems, Sinus Trouble, Recurrent Nose Bleeding

Heart problems: Rheumatic Fever, abnormal heart beat, Chest Pain, Heart Attack, Heart surgery

Vascular disease: High blood pressure, Varicose veins, Poor Circulation

Chest problems: Shortness of Breath, Coughing up Blood, Asthma/bronchitis, Wheezing, Pneumonia,
Pleurisy, TB

Endocrine or hormone disorders: Diabetes or blood sugar problems, Thyroid problem

Malignant Diseases: Cancer or Tumour, Blood disorders

Kidney problems: Urinary Infections, Blood in Urine, Kidney Stones

Genital disorders: Sexually Transmitted Disease

Males: Prostate Disease, Testicular lumps or swellings, Varicocele

Females: Gynae problems, abnormal smears, painful periods, pregnancy problems, Breast lumps

Date of last menstrual period: (exclude Pregnancy)

Skin problems: Dermatitis, Rashes, Exzema, Psoriasis

Infectious/contagious diseases: Malaria or other tropical diseases, HIV / AIDS

Digestive disorder: Frequent Indigestion, Gastric/Duodenal Ulcer, Abdominal Pain Diarrhoea, Constipation,
Bleeding from gut, Jaundice, hepatitis or Liver Complaints, Hernia, Haemorrhoids/piles

Neurological problems: Epilepsy, seizures or Blackouts, Dizziness/fainting, Loss of consciousness, Frequent

Severe headaches or Migraines, Muscular Weakness or Paralysis, Tingling or Numbness, Balance problems,
Stroke, Head Injury or Concussion, loss of memory

Psychiatric problems: Anxiety, Depression, Sleep problems, Nervous Breakdown, suicide attempt

Restricted mobility: Back problems, Sciatica, Fractures, Dislocations, Severe Sprain, Arthritis, Rheumatism,
Joint pain

Apart from conditions as above, have you had any other operations or surgery, serious accidents or injuries, medical problems, diseases or
illnesses, visits to health care professionals or hospital admissions? Yes/No
--------------------------------------------------------------------------------------------------------------------------------------------------------------

I certify that the above medical information is true and any false information provided will be grounds for immediate dismissal. Any failure
to disclose any pre-existing medical condition will be grounds to exclude claims for any illness/injury and other benefits to which I might
otherwise be entitled. The details of my medical examination may be released to my own doctor and also the results may be communicated
to the personnel department of the company/UK Club for whom this examination is carried out.

I hereby authorize the release of all my previous medical records from any health professionals, health institutions and public authorities to
this Examining Physician.

______________________ ___________________________
Signed: (Applicant) Examining Physician Date DD MM YYYY
M
Page 7
January 2019
 EMPLOYMENT PHYSICAL EXAMINATION
To be completed by the Examining Physician.

Height (cm) Weight (kg) BMI (kg/m2) Rate Rhythm Systolic Diastolic
Pulse Blood Pressure
BMI must be under 30

Blood Glucose / Protein

Lung
PEFR FEV1 FVC Urinalysis (+/-)
Function

Systems examination
Normal/Abnormal (give detail) Normal/Abnormal (give detail)
General appearance Vascular (inc. pedal
pulses)
Eyes, pupils Varicose veins

External Ocular Abdomen, inc Hernial

Movements orifices
Opthalmoscopy Genito-urinary(Not
Pelvic Exam)
Ear, inc Tympanic Anus, (Not Rectal
Membrane Exam)
Nose Musculo-skeletal

Throat Spine – Cervical,

thoracic and lumbar
Mouth, Teeth, speech CNS – inc general
neuro exam
Breast examination Lymphatic system

Chest and lungs Skin

Heart Mental capacity

Page 8
January 2019
Required Laboratory Test Results (to be attached)*

See guidelines for requirements for each State whether applicable, Positive/Negative, Normal, or if abnormal give details
test
Electrocardiogram (only for individuals age 50
and above unless extenuating circumstances require
it).
Full Blood Count
Urea, electrolytes, Creatinine,
Glucose, LFTs
Hepatitis A**
Hepatitis B** – HBsAg, if positive other
markers to establish infectivity
Hepatitis C** – anti HCV
Syphilis serology VDRL/RPR
Drug Test Results: (Circle one)
Phencyclidine (PCP) POS NEG Cocaine (COC) POS NEG
Amphetamines (AMP) POS NEG Marijuana (THC) POS NEG
Opiates (OPI) POS NEG

Remarks:

*Examining physician to attach lab test reports separately.

** Hepatitis testing is required one time only for new crew members, or those suspected of being infected.

Based on the examination results above, I find this individual to be (check one):

FIT temporarily UNFIT permanently UNFIT

Name of Doctor: Signature of Doctor:

Date of Examination: DD MM YYYY

Valid Until: DD MM YYYY

Name of examining Clinic/Hospital:

Clinic Stamp:

The original of pages 5 to 10 should be given to the seafarer, a copy kept by the Examining Physician, and a copy sent to Crystal River
Cruises Manning Ltd.

Page 9
January 2019
 Self-declaration – Back and Spine
It is mandatory for all applicants to complete this form. False statements may lead to termination of employment.
Name: D.O.B.

Have you ever suffered from back pain in the past? (Circle one) Yes No
If yes,
1. When? (List year. If more than once, list all years)
2. What symptoms and signs did you have? (Please circle appropriate response)

a. Pain all over? Yes No

b. Low or high back pain? Yes No
c. Pain also when resting? Yes No
d. Pain radiating to buttocks, legs or arms? Yes No
e. Other (please specify)
3. What kind of investigations did you go through: (Please circle appropriate response)
a. Examination by general practitioner or seaman’s doctor. Yes No
If yes, who? Name, Address and Date of exam
b. Examination by specialist? Yes No
If yes, what type of specialist? Name, Address and Date of
exam
c. Examination by other health professionals Yes No
If yes, please indicate type (chiropractor, physiotherapist,
masseur, other)
d. X-rays of back/spine Yes No

e. Ultra sound/sonogram, Bone Scan, MRI or CT Yes No

If yes, Type of exam? Name, Address and Date of exam

4. What was the diagnosis (i.e. what were you told was wrong with your back?)

5. What do you think was the cause:

a. Overwork / Over-exertion? Yes No c. Infection? Yes No

b. Acute injury? Yes No d. Other
6. Did you receive any kind of treatment? Yes No
If Yes, what kind of treatment?
a. Medicine No Yes If yes. What type and how
long?
b. Massage No Yes

c. Physiotherapy No Yes If yes. What type and how

long?
e. Chiropractic No Yes If yes. What type and how
long?
f. Surgery No Yes If yes. What type?

7. Did your back pain lead to:

a. Sick leave from work

b. Medical Sign-Off No Yes If yes, how long?

c. Disability pay No Yes If yes, where? When?
8. How are you now?
(Check one)
Fully recovered
Recovered, but must be careful with certain types of action
State
types:
Still suffer from back pain (Describe)

Name (print) Signature Date

Page 10
January 2019