| TO: |
| Full Name |
| Seafarers Number |
| I have examined you in accordance with the standards of fitness for seafarers, as contained in the Shipping (Medical Fitness) Regulations and found that you are — |
| † * A(T) Fit for full range of duties but for restricted period only |
| † * B Fit for restricted service only |
† C Temporarily unfit for service: For review in (max. 4)
weeks. |
† D Indefinitely unfit for sea service. For review in (max. 6)
months. |
| † E Permanently unfit for service |
| For the following reasons: |
| |
| |
| Official Stamp |
| Signed |
| Name |
| (Recognized duly qualified medical practitioner) |
| Date of Examination (dd/mm/yyyy) |
| * Restrictions, where applicable, are to be detailed in the Medical Fitness Certificate |
| † delete whichever is not applicable |
| Note: Any application for review of the above decision must be lodged in writing on the prescribed form within one month of the date of the examination to Director or if the Director so directs, the Registrar. |