Establishing secure connection…Loading editor…Preparing document…

Biennial National Medical Report

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

BIENNIAL NATIONAL MEDICAL REPORT

(all examinations are in accordance with STCW 95 / MLC 2006 / ILO-IMO GL 2013)

REPORT OF MEDICAL EXAMINATION OF SEAFARER BY THE APPROVED MEDICAL PRACTITIONER

(Approved by General Directorate of Shipping Government of Panama)

Dr.

(the approved Medical Practitioner)

Full Name
M    F
Date of Birth:
Home Address
Nationality
Passport n.°
Type of Vessel
Trade Area
Department
Duty (see below)

I. “Medical History”

Have you ever had any of the following conditions? Yes / No

1. Severe headaches Yes No

2. Head Injury/Concussion/Loss of Memory Yes No

3. Fainting/Seizures/Epilepsy/Balance problems Yes No

4. Eyes/Vision Problems (Glasses, etc.) Yes No

5. Hearing Impairment/Tinnitus Yes No

6. Ear/Nose/Throat problems Yes No

7. Stomach/Bowel/Digestive disorders Yes No

8. Gall stones/Kidney disorders Yes No

9. Jaundice/Liver Disease Yes No

10. Piles/Varicose Veins Yes No

11. Blood Disorder Yes No

12. Female Disorder/Pregnancy Yes No

13. High/Low blood pressure/Heart disease Yes No

14. Asthmas/Bronchitis/Tuberculosis Yes No

15. Diabetes/Thyroid Problem Yes No

16. Allergy/Skin disease Yes No

17. Infection/Contagious Disease Yes No

18. Major/Minor surgery operation Yes No

19. Hernias/Hydrocele/Appendicitis Yes No

20. Fracture/dislocation/Injury/Amputation Yes No

21. Back or joint problems/Restricted mobility Yes No

22. Addiction to Alcohol/Drugs/Tobacco Yes No

23. Nervous/Mental disease/Sleep disorder Yes No

24. Malignant disease (Cancer) Yes No

If “yes” to any of the above questions, please give details:

Additional questions Yes / No

Have you ever been hospitalized, signed off as sick or repatriated from a ship? Yes No

Have you ever been declared unfit for sea duty? Yes No

Has your medical certificate even been restricted/revoked? Yes No

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

Are you aware that you have any medical problems, diseases or illnesses? Yes No

Do you feel healthy and fit to perform the duties of your designated position/occupation? Yes No

Are you allergic to any medication? Yes No

If yes, please list the medications taken, and the purpose(s) and dosage(s):

Comments:

I hereby certify that the personal declaration above is a true statement to the best of my knowledge.

I hereby authorize/not authorize the release of all my previous medical records from any health professionals, health institutions and public authorities to Dr (the approved Medical Practitioner).

Signature of examinee:

Date

II. “Medical Examination”

Height cm.

Weight kg.

Pulse rate /min

Blood Pressure mmHg

Exam Normal Abnormal Exam Normal Abnormal
1. Head & Neck9. Respiratory system
2. Eyes movement/Pupils10. Cardiovascular system
3. Ears/Nose/Throat11. Per Abdomen
4. Teeth/Oral/Cavity12. Genito-urinary system
5. Musculo-Skeletal system13. Mental Capacity
6. Nervous system14. Hernia/hydrocele
7. Reflexes15. Varicose Veins
8. Skin16. Fissure/Fistula/Piles

Comments/Notes:

SIGHT

Use of glasses or contact lenses: Yes/No Yes No

(if yes, specify which type and for what purpose):

Visual Acuity Distant Near
Unaided Aided Unaided Aided
Right eye
Left eye
Binocular

Ishihara Test Normal Defective

Visual Field (Confrontation tests) Normal Defective

Only for look-out duties

Farnsworth Test Normal Defective

Low-contrast vision test Normal Defective

HEARING

Use of hearing aid: Yes/No Yes No

(if yes, specify which type and for what purpose):

Audiometry (see report attached) Threshold values 500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz 6000 Hz
Right Ear <25 dB
Left Ear <25 dB

Speech and Whisper Test (3 metres) Normal Defective

Notes:

III. “Laboratory Test Results”

Complete Blood Count Urinalysis
HemoglobinGlucose
Total WBC countProtein
Neu % / Lymp % / Eos % / Ba % / Mo %Blood
PlateletsOther:
Blood Group
Blood sugarAST (SGOT)
S-CholesterolALT (SGPT)
S-TriglyceridesGamma-GT
AzotemiaOther:
Creatinine

HBs Ag (Hepatitis B Virus) Negative Positive Note:

HCV (Hepatitis C Virus) Negative Positive Note:

Pulmonary TB screening test Negative Positive Note:

VDRL (Syphilide) Negative Positive Note:

CHEST X-Ray Normal Abnormal (see report attached)

ECG (Electrocardiogram) Normal Abnormal (see report attached)

SPIROMETRY Normal Abnormal (see report attached)

Other:

Comments:

IV. “History”

Occupational History

Duty: (risk factors, protective equipments …)

Family History

Father:

Mother:

Partner:

Children:

Collateral

Physiological history

Appetite:

Digestion:

Bowel movements:

Urination/diuresis:

Allergy:

Vaccination:

Lifestyle

Tobacco:

Alcohol:

Coffee:

Sport:

Comments/Notes:

V. “Results of Medical Examination”

Medical Practitioner’s Final Comment:

Assessment of fitness for service at sea

On the basis of the examinee’s personal declaration, my clinical examination and the diagnostic test results recorded above, I declare the examinee medically:

Fit for look-out duty Not fit for look-out duty Not applicable

Visual aid required No Yes

Deck Service Engine Service Catering Service Other Service
Fit
Unfit

With restrictions No Yes

If yes, describe restrictions (e.g., specific position, type of ship, trade area):

Date of medical certificate issued (day/month/year)

Medical certificate’s date of expiration (day/month/year)

Number of medical certificate

Signature of medical practitioner:

Medical practitioner information:

Name:

License N°:

Address:

Panama Authorization:

Crewmember Signature

(I confirm that all Doctor’s comment has been discussed & acknowledged)

Recruiting Agent Stamp

Doctor’s Signature & Stamp

According to MLC 2006, may be possible for the seafarer that have been refused a medical certificate or have had a limitation imposed on his/her ability to work to request a further examination by competent authority, in line with procedures for appeal.

MEDICAL CERTIFICATE FOR CRUISE SHIP PERSONNEL

SURNAME:
NAME:
DATE OF BIRTH:
NATIONALITY:
SEX: Male Female

DECLARATION OF THE AUTHORIZED PHYSICIAN

VISION COLOUR TEST TEST HEARING
Left Eye / Right Eye BOOK LANTERN RIGHT EAR
WITHOUT GLASSESS / WITH GLASSES YELLOW RED LEFT EAR
GREEN BLUE

Confirmation that identification documents were checked at the point of examination: YES NO

Hearing meets the standards in STCW Code, Section A-1/9? YES NO NOT APPLICABLE

Unaided hearing satisfactory? YES NO

Visual acuity meets standards in STCW Code, Section A-1/9? YES NO NOT APPLICABLE

Colour vision meets standars in STCW Code, Section A-1/9? YES NO NOT APPLICABLE

Date of last colour vision test:

Are glasses or contact lenses necessary to meet the required vision standards? YES NO

Able for watchkeeping (Only for Officer/Oiler/AB) YES NO NOT APPLICABLE

Is Applicant taking any non prescription or prescription medication? YES NO NOT APPLICABLE

Is The seafarers free from any medical condition likely to be aggravated by service at sea or to render the seafarers unfit for such service or to endanger the health of other persons on board? YES NO

I declare that I am in knowledge of the contents of the Physical Examination and of the right to a review in accordance with MLC 2006:

Signature of applicant

Name of applicant

Date

Is the crewmember FIT/NOT FIT for duty WITHOUT ANY/WITH THE FOLLOWING restrictions?:

Name and degree of physician:

Address:

Name of Physician's certificating authority:

Date of Issue Physician's Certificate:

Signature of physician:
Stamp of physician:
Date:

Expiring date of certification:

This certificate is issued under authorization of Panama Maritime Authority, in compliance with requirements of STCW 78/95 Convention as amended by Maritime Labour Convention 2006 and the ILO-IMO GL 2013.

According to MLC 2006, may be possible for the seafarer that have been refused a medical certificate or have had a limitation imposed on his/her ability to work to request a further examination by competent authority, in line with procedures for appeal.

Enter text✕
Prepare your document for signing right on this page
  • 01 Edit the text and complete the fields
  • 02 Click Sign Now and on the next screen add recipients and signature fields in SignNow
  • 03 Start your free trial to sign and send your doc
Sign Now

What the Biennial National Medical Report Is

The Biennial National Medical Report is a structured, recurring submission that aggregates standardized health, staffing, and operational metrics from participating institutions every two years. Typical content includes institutional identifiers, aggregated patient counts, selected clinical quality indicators, workforce statistics, and an authorized certification by a designated official. Agencies use the report for national surveillance, trend analysis, and policy planning; providers use it to demonstrate regulatory compliance and support funding or accreditation reviews. Requirements, exact data elements, and submission formats are defined by the receiving federal or state authority and may vary by jurisdiction.

Why the Biennial Report Matters for Institutions

Completing an accurate Biennial National Medical Report ensures compliance with reporting obligations, supports public health monitoring, and preserves institutional eligibility for programs or grants. Clear, consistent data helps regulators track system-level trends and enables institutions to benchmark performance against peers.

Why the Biennial Report Matters for Institutions

Who Typically Prepares and Signs This Report

Several roles collaborate to compile and certify the Biennial National Medical Report.

  • Hospital data officers who aggregate clinical and administrative metrics for submission and validation.
  • Chief medical officers or compliance officers who review clinical measures and attest to accuracy.
  • Health system finance or grants staff who confirm budgetary and staffing figures for reporting purposes.

Responsibilities vary by organization size; establish clear internal ownership and a documented review path before filing.

Step-by-Step: Prepare and Submit the Biennial Report

Follow these sequential steps to collect data, verify accuracy, and submit the report to the receiving agency.

  • 01
    Collect Data: Gather source extracts for the two-year reporting window.
  • 02
    Calculate Metrics: Apply agency-specified formulas and validate denominators.
  • 03
    Internal Review: Compliance and clinical leads review and sign off on values.
  • 04
    Submit Electronically: Upload to the agency portal or e-submit per instructions.

Typical Electronic Submission Workflow

A common online workflow streamlines collection, certification, and archival of the Biennial National Medical Report.

  • Prepare File: Export validated data into the agency template or PDF.
  • Attach Supporting Docs: Include required exhibits, e.g., staffing rosters or calculation worksheets.
  • Authenticate Signer: Authenticate the authorized signatory via email, SMS, or stronger method.
  • Archive: Store signed copy and audit trail in a secure records system.

Essential Sections Within a Professional Biennial Report

A complete report groups data, narrative, certification, and attachments so agencies can evaluate consistency and accuracy.

Header

Contains institutional identifiers, NPI, address, contact person, and reporting period; used to match submissions to agency registries and avoid duplicate records.

Executive Summary

A brief narrative describing major changes, data caveats, or disruptions during the reporting period to guide reviewers and contextualize anomalies.

Aggregate Metrics

Tabulated clinical and operational indicators with clear numerator and denominator definitions following the agency's technical specifications.

Supporting Schedules

Detailed worksheets, sampling methodology, staffing rosters, or calculation files that substantiate reported aggregate values and permit audit.

Certification

Signed attestation by an authorized official confirming the accuracy of submitted data and acknowledging potential penalties for misuse or misreporting.

Attachments

Relevant exhibits such as state licensure documents, data extraction logs, or third-party validation reports referenced in the report.

How to Package Supporting Documents and Exports

Organize supporting files so reviewers can validate metrics without additional requests and preserve a complete audit trail.

Raw Data Exports

Include CSV or Excel extracts used to compute aggregates; label each file with table name and extraction date and keep original query definitions.

Calculation Worksheets

Provide annotated spreadsheets showing formulas and intermediate steps; this reduces back-and-forth and speeds agency reconciliation.

Certifying Letters

Attach a brief signed letter from the certifying official explaining methodology changes or exceptional events that affected data completeness.

Submission Receipt

Retain the agency-generated acknowledgment or confirmation number and store it with the signed report for audit purposes.

Sensitive Data Elements to Protect

Patient Identifiers: Minimize inclusion
Protected Health Information: Encrypt in transit
Staff Personal Data: Limit access
Authentication Logs: Retain securely
Audit Trail: Store immutably
Third-Party Files: Verify vendor BAA

Penalties and Risks for Inaccurate or Late Submission

Regulatory Penalties: Fines possible
Funding Impact: Grant eligibility risk
Reputational Harm: Public reporting consequences
Data Rejection: Agency may return report
Audit Exposure: Triggers additional reviews
Civil Liability: Potential legal claims

Common Preparation Pitfalls to Avoid

  • Using inconsistent date ranges across source systems, which produces mismatched aggregates and triggers agency queries.
  • Entering free-text totals instead of numeric values, causing automated validation to fail and delaying acceptance.
  • Failing to attach calculation worksheets, which often leads to time-consuming agency follow-up and potential audit flags.
  • Missing authorized signature details or using an unauthorized signatory, which can render the submission invalid under institutional policy.

Timing and Key Submission Deadlines

Plan backward from agency deadlines; internal milestones reduce last-minute errors and provide time for corrective actions.

Reporting Frequency:

Biennial — submitted every two years unless agency specifies otherwise.

Internal Compilation Deadline:

Set internal cutoff at least 60 days before external due date.

Final Internal Review:

Complete signatory review 14 days before submission.

External Filing Deadline:

Agency-specific; verify the target agency's published window.

Acknowledgment Receipt:

Retain agency confirmation upon successful upload.

Comparing eSignature Vendors for Biennial Report Workflows

Vendor pricing and features vary; compare starting price, trial options, bulk send support, audit trail availability, HIPAA support, and envelope limits when selecting a platform.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes — available Yes Yes Yes Varies by plan
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes (BAA available) Varies by plan Varies by plan Varies by plan Varies by plan
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Real-World Examples of Digital Reporting and Signoff

These brief examples show how organizations used digital workflows and eSignature to support recurring reporting obligations.

Optica Ventures — Operational Reporting

Optica centralized extraction and standard templates to reduce variance across sites.

  • Implemented a single signatory workflow for corporate attestations.
  • The change reduced data reconciliation time and improved consistency across biennial submissions while preserving a complete audit trail for agency reviewers.

Fertility Centers of Illinois — Clinical Metrics

The center used a prepared calculation workbook to produce aggregate indicators.

  • Adopted an authorized signatory process for certification.
  • This approach expedited internal approvals, provided clear documentation for auditors, and ensured secure storage of signed reports.

Practical Tips for Accurate and Efficient Completion

Adopt repeatable practices to reduce errors, speed approval, and meet legal requirements.

Standardize Extraction Queries and Templates
Use consistent database queries and a single report template across reporting cycles. Document query logic and parameter values so future compilers can reproduce results and auditors can verify computations.
Perform Cross-Checks Before Certification
Institute reconciliation steps that compare raw extracts to final aggregates. Include third-party or peer review of key indicators to catch data anomalies before signatory attestation.
Use Strong Signer Authentication
When possible, require multi-factor authentication or agency-specified credentials for the authorized signatory to strengthen attribution and reduce repudiation risk.
Retain Complete Audit Trails and Receipts
Store signed PDFs, submission confirmations, and system logs in a secure records management system to satisfy retention rules and respond to audits efficiently.

FAQs and Troubleshooting for Common Submission Issues

Answers to frequent questions about validation errors, signature validity, and post-submission corrections.


Need help? Contact support

Explore Templates

New Jersey Complaint Form Civil Case Information Statement
be ready to get more
Join over 28 million airSlate SignNow users
Sign Now
Company
Forms
Pricing
Resources
Knowledge base
Other Products
© 2026 airSlate Inc. All rights reserved.