Seafarer Medical Report Form (ML5)

SEAFARER MEDICAL REPORT FORM (ML5) AND ML5 CERTIFICATE

WHO MAY USE THIS FORM

This form is for use by the following applicants. Please tick why you need this form/certificate:

1. Applicant for an MCA Boatmaster's Licence or Certificate

New applicant Revalidation of existing certificate Change of existing license

2. Applicant for a Royal Yachting Association commercial endorsement for working on Code vessels i.e. those operating under the MCA Codes of Practice for small commercial vessels and the Large Yacht Code (LY2), no more than 60 miles from shore

3. Crew on a seagoing vessel Domestic Passenger vessel

4. Any other reason (please specify)

Note:

Boatmasters working as a Master on a seagoing passenger ship require a full seafarer medical certificate (ENG 1) following examination by an MCA Approved Doctor. An ENG 1 is always an acceptable alternative to an ML5 certificate.

TO THE APPLICANT

WHAT TO DO

1. The purpose of the ML5 form is to obtain a factual report of your medical history and present state of health, enabling your doctor to decide on your fitness to navigate safely and to undertake emergency duties.

2. Applicants for any RYA training are advised to be medically assessed before starting any period of training.

3. If you are based abroad and no UK registered medical practitioner is available, you are advised to obtain an ENG 1 certificate (or recognised equivalent issued by an Approved Doctor).

4. Complete Part A of the form (but do not sign the declaration until you are with the doctor). Complete Part B with your GP, then take/send to RYA or your local MCA Marine Office for endorsement (if applicable).

NOTES ABOUT FITNESS

If you have any ticks in any of the "YES" boxes on the inside of this report, or if you have any medical conditions noted in Section 9, your report may require further assessment by an MCA Medical Assessor.

• you do not meet the MCA's requirements for colour vision/visual acuity

• you are liable to epileptic seizures or sudden disturbances of the state of consciousness

• you have had a coronary thrombosis or heart surgery

• you have problems with heart rhythm, or have a disease of the heart or arteries

• you have abnormal blood pressure that is not well controlled with drugs

• you have diabetes

• you have had a stroke, or unexplained loss of consciousness

• you have had severe head injury with continuing impairment

• you have Parkinson's Disease or Multiple Sclerosis

• you are being treated for psychological or nervous problems

• you have had alcohol or drug dependency problems within the last 5 years

• you have profound deafness and cannot communicate clearly on the radio/telephone

• you have double or tunnel vision

• you have any other condition which could cause problems regarding your fitness to navigate a vessel.

• you are markedly overweight

• your mobility is impaired

PART A - PERSONAL DETAILS

(to be completed by the APPLICANT)

(Please PRINT and use black ink)

PART B - MEDICAL REPORT

(to be completed by the EXAMINING DOCTOR)

Notes for the Doctor

1. Only qualified medical practitioners fully registered and holding a valid Licence to Practice with the General Medical Council are permitted to complete this form.

2. This medical report and certificate is required for applicants who are working on commercially operated boats including passenger boats.

SECTION 1 - CARDIAC

Coronary artery disease

a) Is the applicant having attacks of angina of effort, or receiving continuous treatment to prevent angina from manifesting itself? YES NO

b) Has the applicant had myocardial infarction, unstable angina, or undergone coronary artery bypass surgery or coronary angioplasty? YES NO

If YES, please answer the following:

i) What was the nature of the event?

ii) When was the most recent episode?

iii) If the applicant remains on medication, give details

iv) Give details of any continuing symptoms / clinical signs of heart disease

Arrhythmias

c) Has the applicant uncontrolled complete heart block? YES NO

d) Has a cardiac pacemaker been implanted? YES NO

If YES, when did the applicant last attend a pacemaker clinic?

e) Has a cardioverter / defibrillator device been implanted? YES NO

f) Is there currently a serious or disabling disturbance of cardiac rhythm? YES NO

g) Is the applicant in need of medication to prevent paroxysmal arrhythmia? YES NO

h) Is there evidence of serious congenital heart disease requiring continuing consultant cardiological review? YES NO

i) Is there any history or evidence of heart failure or cardiomyopathy? YES NO

j) Has the applicant undergone heart transplant or heart / lung transplant surgery? YES NO

k) Has the applicant evidence of an aortic aneurysm that has not been successfully treated by surgery? YES NO

l) Is today's resting systolic blood pressure 170 mm Hg or greater? YES NO

Is today's resting diastolic blood pressure 100 mm Hg or greater? YES NO

m) Is there any history of Stroke? YES NO

n) Is there any history of Deep Vein Thrombosis? YES NO

SECTION 2 - ENDOCRINE AND METABOLIC

i) Endocrine disease (thyroid, adrenal including Addison's disease, pituitary, ovaries, testes) YES NO

ii) Diabetes - non insulin treated by diet YES NO

iii) Diabetes - non insulin treated by oral medication YES NO

iv) Diabetes - insulin using YES NO

v) Obesity - BMI over 35 YES NO

SECTION 3 - NERVOUS SYSTEM

a) Has the applicant had any form of epileptic attack? YES NO

i) If YES, please give date of last attack

ii) Is the applicant still being treated? YES NO

iii) If NO, please give the date when treatment ceased

b) Is there a history of blackout or impaired consciousness within the last 5 years? YES NO

c) Does the applicant have narcolepsy/cataplexy or any obstructive sleep apnoea? YES NO

d) Is there a history of, or evidence of any of the conditions listed below? YES NO

SECTION 4 - PSYCHIATRIC ILLNESS

1) A psychotic illness within the past 5 years YES NO

2) A neurotic illness (anxiety/depression) within the past 5 years YES NO

3) Persistent alcohol misuse in the past 12 months YES NO

4) Alcohol dependency in the past 3 years YES NO

5) Persistent drug misuse in the past 12 months YES NO

6) Drug dependency in the past 3 years YES NO

7) Disorder of personality (clinically recognised) YES NO

8) Any other mental health and cognitive disorders YES NO

SECTION 5 - SENSORY

a) Is there any evidence of a colour vision defect as assessed using Ishihara plates? YES NO

b) Does the applicant lack the ability to read 6/6 on the Snellen Chart at six metres distance in at least one eye with glasses or contact lenses if worn? YES NO

c) Does the applicant lack the ability to read 6/60 with at least one eye without any visual aid? YES NO

d) Has the applicant any defects in their field of vision in either eye? YES NO

e) Is there evidence of any progressive disease in either eye? YES NO

f) Does the applicant have any other eye condition which could limit vision, either now or within the next 5 years? YES NO

g) Is there profound deafness that prevents communication by radio/telephone? YES NO

SECTION 6 - MALIGNANT DISEASE

a) Does the applicant have any malignant disease likely to impair physical or mental fitness to undertake duties in the foreseeable future? YES NO

b) Is there a history of bronchogenic carcinoma or other malignant tumour? YES NO

If YES, please give details in Section 9

SECTION 7 - MUSCULOSKELETAL LIMITATIONS

Height (m) Weight (kg)

a) Does the applicant lack the strength and flexibility needed to perform their normal duties such as mooring and lock operations and physically assist other people who have fallen overboard or who need to evacuate the vessel in an emergency? YES NO

b) If the applicant works at sea, do they lack strength and flexibility to get in and out of a moving liferaft? YES NO

c) Is excessive obesity likely to interfere with the activities listed above or prevent access to areas of the vessel with size restrictions? YES NO

d) Is there currently any disability of the spine, limbs or hands likely to limit duties or safety procedures while working? YES NO

e) Has the applicant had a hip/knee replacement or other limb prosthesis? YES NO

f) Does the applicant lack sufficient fitness to be responsible for the safety of fare paying passengers? YES NO

SECTION 8 - RESPIRATORY SYSTEM

a) Is there a history of, or evidence of any of the conditions listed below:

i) Sinusitis / Nasal Obstruction YES NO

ii) Chronic Bronchitis and / or Emphysema YES NO

iii) Pneumothorax YES NO

iv) Asthma YES NO

SECTION 9 - OTHER MEDICAL CONDITIONS / ADDITIONAL INFORMATION

If you have ticked YES to any of the above questions or have written in the boxes below and so are not able to issue a certificate, this form will be referred to one of the MCA's Medical Assessors.

a) Additional information to assist the Assessor

b) Medical condition not included in the list of questions

c) Is the applicant taking any medication that can impair safety critical duties? YES NO

Medication details

d) Is the applicant taking any medication with risk of acute complications? YES NO

Medication details

SECTION 10 - DECLARATION BY EXAMINING DOCTOR

I certify that I have examined the applicant named in PART A and that my findings are recorded above in PART B of this report.

a) There are no ticks in any "YES" box and I have completed the ML5 certificate proforma at PART C and retained a copy.
b) There are ticks in the "YES" boxes in Section 1 - 8.
c) There is any other significant medical condition detailed in Section 9.

* Delete a, b or c as appropriate.

PART C - ML5 CERTIFICATE

(to be completed by the EXAMINING DOCTOR)

Notes for the completion of Part C

1. If you have not ticked any "YES" Box in Part B and have not made comments in Section 9, please complete the following certificate proforma at Part C.

2. A copy of the certificate should be retained by the Doctor for verification purposes.

ML5 CERTIFICATE OF MEDICAL FITNESS

This is to certify that the following applicant has been assessed by me for medical fitness in accordance with the criteria specified by the MCA in the ML5 form and all assessment ticks are in the "NO" box.

Surname

Forename(s)

Date of Birth

Home Address

Postcode

Signed (Medical Practitioner)

Name (Block Letters)

Address

Postcode

GMC Registration Number

Certificate valid until

Date issued

Name of RYA / MO Endorsing Officer

Signature

Signature of Holder

Date

PART D - MEDICAL REVIEW

(to be completed by the APPLICANT where appropriate)

a) Details of vessel

b) Proposed area of operation

Up to miles from point of departure

Up to miles offshore

Longest length of trip

Area of Operation (including Category of Water)

c) Type of operation involved

d) Other relevant risk factors

e) Minimum number of crew (other than applicant)

f) Passengers (where applicable) Maximum number of fare-paying passengers carried

g) Medication (Please list all prescribed medication you are currently taking including dosage).

h) Details of any regular review/monitoring of condition

PART D - CONTINUATION BOX