Can this form be signed electronically?

Yes. In the United States, electronic signatures that satisfy the ESIGN Act (15 U.S.C. ch. 96) and applicable state UETA rules are legally valid, provided the signature demonstrates intent, consent, attribution, and retention. For PHI, ensure HIPAA safeguards and a BAA with the vendor.

Who must sign the examiner section?

The licensed medical examiner who performed the assessment must sign and provide licensure information. Employer or crewing agents may acknowledge receipt but should not sign examiner attestations.

How do I correct an error on a completed record?

Do not alter the original. The examiner should issue an addendum or corrected record that references the original date and explains the correction. Maintain both versions in the audit trail.

How long must employers retain the record?

Retention depends on statutes and employer policy. HIPAA requires six years for certain records (45 CFR §164.530(j)); employers frequently retain for at least the employment term plus three years. Consult legal counsel for specific obligations.

Is patient consent required to share results?

Sharing with the employer for occupational reasons is a permitted use under many frameworks, but sensitive PHI disclosures may require written consent or rely on permitted-use exceptions; follow HIPAA and state privacy laws.

What if a regulatory body rejects the electronic copy?

Confirm the rejection reason (format, signature authentication, missing credentials). If rejected for signature method, provide a certified paper copy or use a higher-assurance digital signature that meets the regulator’s requirements.

Electronic Signature
Templates
Healthcare
Record of Medical Examinations of Seafarer

Record of Medical Examinations of Seafarer

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

RECORD OF MEDICAL EXAMINATIONS OF SEAFARERS – April 2013

MARITIME AND PORT AUTHORITY OF SINGAPORE
SHIPPING DIVISION

RECORD OF MEDICAL EXAMINATIONS OF SEAFARER

Part A – to be completed by the Seafarer who is responsible for answering each question accurately.

Seafarer’s Name in Full (BLOCK CAPITALS)

Sex

Date of Birth

Place of Birth

Nationality

Type of ID documents: NRIC No. / Passport No.

Dept: Deck / Engine / Catering / others

Type of ship

Home Address

Routine and emergency duties

Trading area

Seafarer’s Declarations (please tick)

Have you ever had any of the following conditions?

1. Eye/vision problem

2. High blood pressure

3. Heart/vascular disease

4. Heart Surgery

5. Varicose veins/piles

6. Asthma/bronchitis

7. Blood disorder

8. Diabetes

9. Thyroid problem

10. Digestive disorder

11. Kidney problem

12. Skin Problem

13. Allergies

14. Infectious / contagious diseases

15. Hernia

16. Genital disorder

17. Pregnancy

18. Sleep problem

19. Do you smoke, use alcohol or drugs?

20. Operation/surgery

21. Epilesy/seizures

22. Dizziness/fainting

23. Loss of consciousness

24. Psychiatric problems

25. Depression

26. Attempted suicide

27. Loss of memory

28. Balance problem

29. Severe headaches

30. Ear(hearing, tinnitus/nose/throat problem

31. Restricted mobility

32. Back or joint problem

33. Amputation

34. Fracture/dislocations

If you answer “yes” to any of the above questions, please provide details:

Additional questions

35. Have you ever been signed off as sick or repatriated from a ship?

36. Have you ever been hospitalized?

37. Have you ever been declared unfit for sea duty?

Part B – Result of medical examinations

Eyesight

Use of glasses or contact lenses

No

Yes

Visual Acuity

	Unaided			Aided
	Right eye	Left eye	Binocular	Right eye	Left eye	Binocular
Distant
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
Right ear
Left ear

Speech and whisper test (metres)

	Normal	Whisper
Right ear
Left ear

Clinical Findings

Height		Weight
Pulse rate		Rhythm
Blood Pressure Systolic		Diastolic
Urinalysis: Glucose		Protein
Blood

	Normal	Abnormal
Head
Sinus, nose, throat
Mouth/teeth
Ears (general)
Tympanic membrane
Eyes
Ophthalmoscopy
Pupils
Eye movement
Lungs and chest
Breast examination
Heart
Skin
Varicose Vein
Vascular (inc. pedal pulse)
Abdomen and viscera
Hernia
Anus (not rectal exam)
G-U system
Upper and lower extremities
Spine (C/s, T/S, L/S)
Neurologic (full/brief)
Psychiatric
General appearance

Chest X-ray

Not performed

Performed on (day/month/year)

Results:

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

Medical practitioner’s comments and assessment of fitness, with reasons for any limitations.

Assessment of fitness for service at sea (please tick)

On the basis of the seafarer’s personal declaration, my clinical examination and diagnostic test 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 Service	Engine Service	Catering Service	Other Service
Fit
Unfit

Without restrictions With restrictions

Description of restrictions (e.g. specific position, type of ship, trading area etc.)

Date

Signature of Medical Practitioner

Medical Practitioner’s name, licence number, address

What the Record of Medical Examinations of Seafarer Is

The Record of Medical Examinations of Seafarer is an official medical report documenting a seafarer’s physical and mental fitness for duty aboard commercial vessels. It records examiner identification, medical history, physical exam findings, vision and hearing test results, laboratory or drug-screen outcomes, and any limitations or restrictions. The form serves employers, flag states, and port authorities as evidence of fitness for specific duties and can be required for licensing, certification, or boarding clearance. Proper completion supports compliance with maritime health and safety expectations and helps manage occupational risk.

Why a Complete Medical Examination Record Matters

A thorough, accurate record protects the seafarer, the employer, and other crew by documenting fitness, restrictions, and follow-up needs while supporting regulatory compliance and continuity of care.

Primary Users and Recipients of This Medical Record

Each user group has different retention, confidentiality, and submission responsibilities under workplace, maritime, and health privacy rules.

Employers and crewing agencies who verify fitness for duty and retain records for safety and payroll purposes.
Designated maritime medical examiners who perform the assessment and certify fitness or restrictions for seafaring duties.
Port and flag-state authorities, licensing bodies, and insurers that may require medical evidence for certification and claims.

Core Components of a Professional Medical Examination Record

A well-structured record groups identity, exam findings, testing results, certifications, examiner details, and follow-up instructions to create a complete clinical and administrative picture.

Seafarer Identity

Full legal name, date of birth, nationality, seafarer ID or license number, and current employer information for unambiguous identification.

Medical History

Brief occupational and medical history including chronic conditions, medications, prior surgeries, and conditions affecting sea duty or safety-critical tasks.

Physical Examination

Systematic findings (cardiovascular, respiratory, neurological, musculoskeletal) with clear statements about functional limitations or fitness for duty.

Sensory and Lab Tests

Vision, hearing, and any required laboratory results (drug and alcohol screens, relevant bloodwork) with measured values and pass/fail indicators.

Examiner Certification

Name, professional license number, issuing state or country, signature, and date certifying the exam and its conclusions.

Restrictions & Follow-up

Clear description of work limitations, recommended monitoring, referral instructions, and the recommended interval for re-examination.

Step-by-Step: Completing and Submitting the Medical Record

Follow these sequential steps to reduce errors and ensure timely acceptance by employers and authorities.

01

Schedule Exam: Book with an approved maritime medical examiner or clinic.
02

Complete Intake: Provide accurate history, IDs, and required documentation.
03

Undergo Examination: Complete physical, vision, hearing, and any lab tests.
04

Sign and Submit: Examiner signs; employer or seafarer submits per policy.

Configuring an Online Workflow for This Form

Design a digital flow that mirrors the paper process: intake, exam completion, examiner signature, employer retention, and secure distribution.

Field	Configuration
Intake Form	Collect identity and history before appointment.
Exam Fields	Lock key clinical fields to medical roles.
Signature Step	Require authenticated signer for examiner role.
Distribution	Auto-send completed PDF to employer and seafarer.

Typical Routing: Who Receives the Completed Record

A clear, auditable route ensures records reach all required parties while maintaining privacy and chain-of-custody.

Seafarer: Receives the finalized copy for personal records.
Employer: Receives copy for crewing, compliance, and payroll.
Regulatory Body: Sent to flag-state or licensing body when required.
Health Records: Stored securely in employer’s medical file with access controls.

Technical Requirements for Digital Completion and eSubmission

Verify the chosen platform meets legal, privacy, and employer-specific rules before relying on electronic submission of medical examination records.

Authentication: Email, SMS, or stronger methods required.
Audit Trail: Must record timestamps and signer attribution.
Document Formats: PDF and DOCX export for retention.

Timing and Renewal Considerations

Timing affects deployment and certification: plan exams and renewals in advance to avoid service interruptions.

Pre-Deployment Exam:

Complete before embarkation; allow time for scheduling and results.

Renewal Window:

Follow employer or flag-state guidance on renewal intervals; schedule ahead of expiration.

Processing Time:

Allow several days for lab results and electronic routing when required.

Conditional Re-exam:

If restrictions are noted, confirm follow-up timelines with the examiner.

Record Updates:

Update medical records promptly when duties or medical status change.

Key Milestones from Exam to Record Acceptance

Track milestone stages so seafarers and employers can monitor progress and identify bottlenecks.

01

Appointment Scheduled

Seafarer booked with approved medical examiner.

02

Examination Completed

Clinical tests and forms completed by examiner.

03

Certification Issued

Examiner signs and certifies fitness or restrictions.

04

Submission & Filing

Record delivered to employer and stored in secure system.

Common Preparation Errors to Avoid

Incomplete identification fields delaying verification and certification.
Missing examiner credentials or unsigned certification sections invalidating the form.
Illegible handwriting on paper forms leading to misinterpretation or rework.
Uploading wrong document versions or failing to remove non-relevant pages.

Consequences of Incorrect or Incomplete Records

Denied Boarding: Crew denied ship access.

Job Suspension: Temporary removal from duty.

Insurance Claim Risk: Claims may be reduced or denied.

Regulatory Rejection: Certification not accepted by authority.

Fines: Civil penalties may apply.

Data Breach Liability: HIPAA violations can incur penalties.

Security and Privacy Essentials for Medical Records

Encryption: AES-256 at rest; TLS 1.2/1.3 in transit

Access Controls: Role-based permissions and strong passwords

Audit Logs: Timestamped history of access and signatures

HIPAA BAA: Business Associate Agreement required for PHI

Secure Backups: Redundant backups with integrity checks

Regulatory Certs: SOC 2 and ISO 27001 attestations

eSignature Vendor Comparison for Medical Examination Records

Comparison of typical vendor pricing and compliance features relevant to signing and securely storing medical examination records; signNow is listed first per platform selection guidelines.

	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	Yes, 7-day free trial	Varies by offer	Varies by offer	Yes, varies	Yes, varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently Asked Questions About the Medical Examination Record

Answers to common questions about validity, electronic signing, corrections, retention, and privacy when using medical examination records for seafarers.

Need help? Contact support

Can this form be signed electronically?
Yes. In the United States, electronic signatures that satisfy the ESIGN Act (15 U.S.C. ch. 96) and applicable state UETA rules are legally valid, provided the signature demonstrates intent, consent, attribution, and retention. For PHI, ensure HIPAA safeguards and a BAA with the vendor.
Who must sign the examiner section?
The licensed medical examiner who performed the assessment must sign and provide licensure information. Employer or crewing agents may acknowledge receipt but should not sign examiner attestations.
How do I correct an error on a completed record?
Do not alter the original. The examiner should issue an addendum or corrected record that references the original date and explains the correction. Maintain both versions in the audit trail.
How long must employers retain the record?
Retention depends on statutes and employer policy. HIPAA requires six years for certain records (45 CFR §164.530(j)); employers frequently retain for at least the employment term plus three years. Consult legal counsel for specific obligations.
Is patient consent required to share results?
Sharing with the employer for occupational reasons is a permitted use under many frameworks, but sensitive PHI disclosures may require written consent or rely on permitted-use exceptions; follow HIPAA and state privacy laws.
What if a regulatory body rejects the electronic copy?
Confirm the rejection reason (format, signature authentication, missing credentials). If rejected for signature method, provide a certified paper copy or use a higher-assurance digital signature that meets the regulator’s requirements.

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