Cg 719K Form PDF Details

Cg 719K Form is a new product that has been released by the company CG. This product is designed to help people with their tax forms and ensure that they are able to get the best possible return on their taxes. This product is also designed to be easy to use, making it a great option for people who are not used to doing their own taxes. If you are looking for a great way to get your taxes done right, this may be the perfect option for you. Cg 719K Form is sure to make your life easier when it comes time to do your taxes.

QuestionAnswer
Form NameCg 719K Form
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namescg 719, uscg application pdf, cg719k, uscg certificate pdf

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DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard

APPLICATION FOR MEDICAL CERTIFICATE (FORM CG-719K)

OMB No. 1625-0040

Exp. Date: 03/31/2021

------ Instructions ------

Who must submit this form?

1.Applicants seeking a Medical Certificate are required to complete this form and submit all 10 pages, including instructions, to the U.S. Coast Guard. Guidance for completion of this form can be found at https://www.uscg.mil/hq/cg5/nvic/pdf/2008/NVIC_04-08.pdf.

2.Mariners applying for or holding a merchant mariner credential with only an entry-level endorsement who serve on a vessel not subject to the International Convention on Standards of Training, Certification and Watchkeeping (STCW) but who request a medical certificate that satisfies the Maritime Labor Convention (MLC), AND want to be qualified for lookout duties should submit this form. Sections III (Medical Conditions), IV (Medications) and V (Physical Examination) of the CG 719K DO NOT have to be completed. The medical certificate will be restricted to entry-level only.

3.The Coast Guard will not accept an application for a medical certificate without a reference number or a Merchant Mariner Credential (MMC).

Who may conduct this exam?

1.All exams, tests and demonstrations must be performed, witnessed or reviewed by a physician, physician assistant, or nurse practitioner licensed by a state in the U.S., a U.S. possession, or a U.S. territory.

2.Medical examinations for U.S. Registered Pilots must be conducted by a licensed medical doctor.

Section I: Applicant Information - To be completed by the Applicant and reviewed by the Medical Practitioner (MP)

•Legal Name - Enter complete legal name.

•Date of Birth - If applicant is under 18 years of age, attach a notarized statement, signed by a parent or guardian, authorizing the Coast Guard to issue a Medical Certificate.

•Mariner Reference Number or Social Security Number - If you have held a Coast Guard credential in the past, enter your reference number.

•Gender - Enter your gender.

•Home Address - Principle place of residence. PO Box is not acceptable.

•Delivery/Mailing Address - The address to which you want all correspondence and issued certificates sent. If blank, correspondence and certificates will be sent to the Home Address.

•Primary Phone Number - Provide a primary phone number.

•Alternate Phone Number - Provide an alternate phone number (optional).

•E-mail Address - (Optional) If provided, the National Maritime Center (NMC) may attempt to contact you via e-mail. You will receive automated updates regarding the status of your application.

•Other - Please provide additional means of communicating with you (satellite phone, work phone, etc.) (optional).

•Endorsement held or sought - Applicants should select all options that apply. If nothing is selected, the Coast Guard will not accept the application.

Section II: Food Handler Certification - To be completed by the Medical Practitioner

Refer to instructions provided in this section. The Medical Practitioner should initial and date at the bottom of each page of the application, where indicated.

Section III: Medical Conditions - To be completed by the Applicant and the Medical Practitioner

III(a) Applicants must report their relevant medical conditions to the best of their knowledge. Applicants should check YES if: 1) they have had a previous diagnosis, or treatment for the condition by a health care provider; 2) they are currently under treatment or observation for the condition; or 3) the condition is present, regardless of treatment status.

III(b) The Medical Practitioner must review and discuss all conditions reported by the applicant in Section III(a). The Medical Practitioner's discussion should include, at a minimum, the name of the condition, approximate date of diagnosis, treatment, current status of the condition, limitations of the condition, and any additional information as appropriate. Recommended supporting documentation and testing for conditions that are subject to further review are contained in the Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials which can be found at https://www.uscg.mil/hq/cg5/nvic/ pdf/2008/NVIC_04-08.pdf. Medical practitioners should be familiar with the guidelines contained within this document. If the Medical Practitioner discovers a condition not reported by the applicant, they must check YES in the appropriate block in III(a) and provide information on the condition, as requested, in Section III(b). For conditions that were Previously Reported, the Medical Practitioner need only discuss the interval history and current status of the condition. Additional sheets may be added by the applicant and/or the medical practitioner if needed to complete this section of the form. Include applicant's name and DOB on each additional sheet. The Medical Practitioner should initial and date at the bottom of each page of the application, where indicated.

MEDICAL PRACTITIONER INITIALS:

DATE:

Print Applicant Name:(Last, First, MI.)

Date of Birth: (MM/DD/YYYY)

CG-719K (04/17)

Previous Editions Obsolete

Page 1 of 10

Section IV: Medications - To be completed by the Applicant and reviewed by the Medical Practitioner

Applicants - Refer to instructions provided in this section.

Medical Practitioner - Verification of medications includes questioning the applicant about any medications or other substances reported, reviewing relevant medical conditions to determine if the applicant has omitted any medications or other substances, and affirmatively reporting any omitted current medications or other substances where required. The Medical Practitioner should initial and date at the bottom of each page of the application, where indicated.

Section V: Physical Examination - Items 1-17; To be performed and completed by the Medical Practitioner

The Medical Practitioner must document the results of the physical examination in this section. The Medical Practitioner should initial and date at the bottom of each page of the application, where indicated.

Section VI: (Vision) and VII: (Hearing) - To be completed by the Medical Practitioner or other staff to the satisfaction of the Medical Practitioner

The Medical Practitioner is not required to perform or witness the vision and hearing examinations. These may be performed by qualified office staff or referred to other qualified practitioners such as audiologists or optometrists; however, the results must be reviewed by the Medical Practitioner.

The Medical Practitioner should initial and date at the bottom of each page of the application, where indicated.

Additional guidance can be found at: https://www.uscg.mil/hq/cg5/nvic/pdf/2008/NVIC_04-08.pdf.

Section VIII: Demonstration of Physical Ability - To be completed by the Medical Practitioner

Refer to the table and instructions provided in this section. The Medical Practitioner should initial and date at the bottom of each page of the application, where indicated.

Section IX: Summary - To be completed by the Medical Practitioner

a. Applicant Proof of Identity Provided - Applicants shall present acceptable proof of identity to the Medical Practitioner conducting examinations. Proof of identity shall consist of one current form of valid government-issued photo identification. Examples of acceptable proof of identity include unexpired official identification issued by a Federal, State, or local government or by a territory or possession of the United States, such as a passport, U.S. driver's license, U.S. military ID card, Merchant Mariner Credential, or Transportation Worker Identification Credential.

b. Certification recommendation - The Medical Practitioner must ensure a complete history and physical are conducted. The practitioner should address the listed questions and make a certification recommendation. The Coast Guard retains final authority for the issuance of the medical certificate.

c.Assessment - The Medical Practitioner should provide answer to statement 1 or 2, as appropriate for the credential sought. Option 2 is for mariner applicants who are only seeking an MLC-compliant, entry-level medical certificate.

d.Discussion - The Medical Practitioner should discuss any conditions or issues of concern.

e.Medical Practitioner (Attestation and Information) - Attests that the general medical examination, vision and hearing tests, and demonstration of physical ability, as appropriate, have been performed to the satisfaction of the Medical Practitioner. The Medical Practitioner must sign and date the attestation where indicated. This signature attests, subject to criminal prosecution under 18 USC § 1001, that all information reported by the Medical Practitioner is true and correct to the best of their knowledge and that the Medical Practitioner has not knowingly omitted or falsified any material information relevant to this form.

Section X: Applicant Certification - To be completed by the Applicant

Applicant certifies that the information provided is true and correct.

Section XI: Applicant Consent (optional) - To be completed by the Applicant

Third Party Authorization - If you want the NMC to be able to discuss, release, or receive information/documents regarding your medical certificate application with a third party (spouse, employer, school, union, etc.) you must provide specific guidance to the NMC regarding what issues we may discuss and with whom. You may allow release of all information to certain individuals or entities. If you limit the release of certain information you must be specific by making a selection on the application or by attaching additional documentation. For each selection made, ensure the Name of the Organization or Third Party, Organization Point of Contact (if applicable), Address and Phone Number is completed. If you wish to provide multiple Third Party Authorizations, attach additional pages as needed. A sample may be found on the NMC website: https://www.uscg.mil/nmc/credentials/forms/3rd_party_authorization_med_cert.pdf. Please sign and date for each type of consent that you wish to authorize.

a.Consent for Medical Practitioner to Release Information to the Coast Guard

b.Consent for Coast Guard to Release Information to a Third Party

c.Consent for Third Party to Act on your Behalf

MEDICAL PRACTITIONER INITIALS:

DATE:

Print Applicant Name:(Last, First, MI.)

Date of Birth: (MM/DD/YYYY)

CG-719K (04/17)

Previous Editions Obsolete

Page 2 of 10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OF HOMELAND SECURITY

 

OMB No. 1625-0040

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Coast Guard

 

Exp. Date: 03/31/2021

 

 

 

 

 

 

 

 

 

 

 

APPLICATION FOR MEDICAL CERTIFCATE (FORM CG-719K)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section I: Applicant Information - To be completed by the Applicant and reviewed by the Medical Practitioner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

 

 

 

 

First Name

 

 

 

 

 

 

 

 

 

Middle Name

Suffix (Jr., Sr., III)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mariner Reference Number or Social Security Number

 

 

 

 

 

Gender:

 

 

 

 

 

 

 

 

Date of Birth (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please indicate best method(s) of contact by checking the appropriate box(es).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Address (PO Box NOT acceptable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

Alternate Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Delivery/Mailing Address, if different

 

(PO Box acceptable)

 

 

 

 

 

 

 

 

 

E-mail Address

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Endorsement Held or Sought (Check all that apply or the Coast Guard will not accept the application):

 

 

 

 

 

 

 

 

Deck

 

Engine

 

 

Food Handler

 

 

STCW

 

 

 

 

 

Entry-level with lookout duties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Registered Pilot (Great Lakes Pilotage)

 

 

 

First-Class Pilot or those Serving as Pilot (Federal Pilotage/46 CFR 15.812)

 

 

 

 

 

 

 

 

 

 

 

Other (Please explain):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section II: Food Handler Certification - To be completed by the Medical Practitioner

1. Food Handlers must obtain a statement from the Medical Practitioner that attests that they are free of communicable diseases that pose a direct threat to the health or safety of other individuals in the workplace. For applicants who have requested Food Handler Certification (Food Handler box is checked in Section I, above), the Medical Practitioner may provide the attestation by answering Yes or No to the question in bold below.

2. Communicable disease is defined in 46 CFR 10.107 as any disease capable of being transmitted from one person to another directly, by contact with excreta or other discharges from the body; or indirectly, via substances or inanimate objects contaminated with excreta or other discharges from an infected person.

3. The Medical Practitioner need not perform any additional testing unless it is deemed clinically necessary. Applicants and currently employed food workers should report information about their health as it relates to diseases that are transmissible through food. Circumstances that the Medical Practitioner should consider when certifying an applicant include, but are not limited to, the following:

a. Whether the applicant reports they have been diagnosed with, or exposed to an illness due to organisms including, but not limited to, Salmonella Typhi, Shigella Spp., Shiga-toxin-producing Escherichia coli, or Hepatitis A virus within the past month.

b. Whether the applicant reports they have at least one symptom caused by illness, infection, or other source that is associated with an acute gastrointestinal illness such as diarrhea, fever, vomiting, jaundice, or sore throat with fever.

c. Whether the applicant reports they have a lesion containing pus, such as a boil or infected wound, which is open or draining and is on hands or wrists or

on exposed portions of the arms.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the applicant free from communicable disease?

 

Yes

 

 

No

 

N/A

 

 

MEDICAL PRACTITIONER INITIALS:

 

DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CG-719K (04/17)

Previous Editions Obsolete

Page 3 of 10

Print Applicant Name:(Last, First, MI.)

Date of Birth: (MM/DD/YYYY)

Section III(a): Medical Conditions - To be completed by the Applicant and reviewed by the Medical Practitioner

I have a medical waiver (MW):

 

Yes

 

No If YES, provide a copy to the Medical Practitioner, and mark the MW box below.

To the best of your knowledge, have you ever had, required treatment for, or do you presently have any of the following conditions? If no, please mark the NO box below. If yes, please mark the YES box below, and if previously reported (PR), mark the PR box below.

ITEM YES NO PR MW CONDITIONS

1.

1.

Blurry vision, poor night vision, eye disease or injury, eye surgery, abnormal color vision, cataracts or glaucoma

 

 

 

2.

2.

Hearing loss, hearing aid, ear surgery, facial deformities, open tracheostomy or frequent severe nose bleeds

 

 

 

3.

3.

High or low blood pressure

 

 

4.

4. Heart or vascular disease of any kind, to include angina, chest pain, irregular heart beat, heart valve problem/

 

replacement, heart attack/myocardial infarction, or congestive heart failure

 

 

5.

5.

Heart surgery and/or implanted devices (for example, angioplasty, stent, pacemaker, or defibrillator)

 

 

 

6.

6.

Lung disease of any type (for example, asthma, emphysema, or chronic obstructive pulmonary disease (COPD))

 

 

 

7.

7.

Any blood disorder (for example, anemia, hemophilia, blood clots, or polycythemia)

 

 

 

8.

8.

Diabetes, glucose intolerance, or sugar in urine

 

 

 

9.

9.

Thyroid problem requiring treatment or hospitalization

 

 

 

10.

10.

Stomach, liver or intestinal disorder requiring ongoing medical care/medication, or causing significant bleeding

 

or debilitating pain; history of hepatitis or jaundice

 

 

11.

11.

Kidney problems/stones or blood in urine

12.

12.

Any other urinary or bladder problems not listed above requiring treatment or hospitalization

 

 

 

13.

13.

Skin disorders requiring medical treatment, such as cancer, tumors, scleroderma or lupus

 

 

 

14.

14.

Severe allergies or allergic reactions to any substance, medication, food, or insect stings

15.

15.

Communicable disease or chronic infectious diseases such as tuberculosis, HIV/AIDS, or hepatitis

 

 

 

16.

16.

Any sleep problems (for example, obstructive sleep apnea, restless leg syndrome, narcolepsy, shift work

 

sleep disorder, or insomnia)

 

 

17.

17.

Epilepsy, fits, or seizures

 

 

 

18.

18.

History of serious head injury, loss of consciousness or memory loss

 

 

 

19.

19.

Frequent or severe headaches

 

 

 

20.

20.

Dizziness/fainting spells/balance problems

 

 

 

21.

21.

Frequent motion sickness requiring medication

 

 

 

22.

22.

Stroke or Transient Ischemic Attack (TIA), brain tumor or other brain disorder

 

 

 

23.

23.

Any neurologic disorder or nerve problems including numbness and/or paralysis, not listed above

 

 

 

24.

24.

Attention deficit disorder with or without hyperactivity

 

 

 

25.

25.

Anxiety, depression, bipolar disorder, adjustment disorder, PTSD, or schizophrenia

 

 

 

26.

26.

Suicide attempt or thought(s) of suicide (Suicidal Ideation)

 

 

 

27.

27.

Evaluation, treatment, or hospitalization for alcohol or substance use, abuse, addiction, or dependence

 

(including illegal drugs, prescription medications, or other substances)

 

 

28.

28.

Any other psychiatric disorder, mental health evaluation/treatment/hospitalization

 

 

 

29.

29.

Back, neck or joint problems that impair movement or cause debilitating pain

 

 

 

30.

30.

Amputation, prosthesis, or use of ambulatory devices (for example, cane, walker, or braces)

31.

31.

Injuries, fractures or recurrent dislocations causing impairment or limitation of motion of any joint

 

 

 

32.

32.

Have you ever been signed off a vessel as sick or repatriated for medical reasons within the last six years?

33.

33.

Any diseases, surgeries, cancers, illnesses, or disabilities not listed on this form?

34.

34.

Any hospital admissions within the last six years not listed elsewhere in this Section?

 

 

 

MEDICAL PRACTITIONER INITIALS:

DATE:

CG-719K (04/17)

Previous Editions Obsolete

Page 4 of 10

Print Applicant Name:(Last, First, MI.)

Date of Birth: (MM/DD/YYYY)

Section III(b): Medical Conditions - To be completed by the Medical Practitioner

Instructions: For each item marked YES in Section III(a), the Medical Practitioner must provide the information requested IN THE BLOCKS below. For each condition marked Previously Reported (PR), the provider need only discuss the interval history and current status of the condition.

For conditions with a Medical Waiver (MW) review the applicant's waiver letter and attach all waiver reporting requirements.

Please attach appropriate evaluation data for conditions that are subject to further review. Information on conditions that are subject to further review and the recommended evaluation data can be found in the Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials, located at https://www.uscg.mil/hq/cg5/nvic/pdf/2008/NVIC_04-08.pdf.

Indicate whether additional information has been attached by marking the ATTACHED box. Additional sheets may be added, if needed to complete this section (include applicant name and date of birth on each additional sheet).

Item #

 

Date of onset or diagnosis (mm/dd/yyyy)

 

 

 

 

 

 

 

Condition

 

 

 

Treatment

 

 

 

 

 

 

 

 

 

 

 

 

Status

 

 

 

Limitations

 

 

 

 

 

 

Attached

Item #

 

Date of onset or diagnosis (mm/dd/yyyy)

 

 

 

 

 

 

 

 

Condition

 

 

 

 

Treatment

 

 

 

 

 

 

 

 

Status

 

 

 

 

Limitations

 

 

 

 

 

 

 

 

Item #

 

 

Date of onset or diagnosis (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Condition

 

 

 

 

Treatment

 

 

 

 

 

 

 

 

Status

 

 

 

 

Limitations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attached

Attached

Item #

 

Date of onset or diagnosis (mm/dd/yyyy)

 

 

 

Condition

 

 

 

 

Treatment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Status

 

 

 

 

Limitations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Item #

 

Date of onset or diagnosis (mm/dd/yyyy)

 

 

 

 

 

 

 

 

Condition

 

 

 

 

Treatment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Status

 

 

 

 

Limitations

 

 

 

 

 

 

 

 

Attached

Attached

MEDICAL PRACTITIONER INITIALS:

DATE:

CG-719K (04/17)

Previous Editions Obsolete

Page 5 of 10

Print Applicant Name:(Last, First, MI.)

 

Date of Birth: (MM/DD/YYYY)

 

 

 

Section IV: Medications - To be completed by the Applicant and reviewed by the Medical Practitioner

 

Do you currently use any medication (prescription or nonprescription)?

 

 

Yes

 

 

 

No If YES, provide the information requested in the blocks below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicants Must Report

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Practitioner

 

 

 

 

 

 

 

 

 

 

 

 

 

1. All medications (Prescription or Nonprescription), dietary supplements, and

 

 

 

 

1. Medical Practitioner must verify applicants medications and information

 

 

vitamins; that were filled, or refilled, and/or taken within 30 days prior to the date

 

 

listed in the table below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the applicant signs the CG-719K; and

 

 

 

 

 

 

 

 

 

 

 

2. Medical Practitioner comments should include the approximate length

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. All medications (Prescription or Nonprescription), dietary supplements, and

 

 

 

 

 

of time the applicant has taken the medication and address the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

vitamins that were used for a period of 30 or more days within the last 90 days

 

 

 

 

 

presence or absence of any side effects.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

prior to the date the applicant signs the CG-719K.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional guidance on medications, including those that may be considered disqualifying, can be found at

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

https://www.uscg.mil/hq/cg5/nvic/pdf/2008/NVIC_04-08.pdf.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional sheets may be attached by the Applicant and/or Medical Practitioner if needed to complete this section.

ATTACHED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Include applicant name and date of birth on each additional sheet and check the box indicated on the right)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICATION

DOSE

FREQUENCY

 

 

 

 

 

CONDITION

 

 

MEDICAL PRACTITIONER COMMENTS (Duration of Use/Side Effects)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REPORT OF MEDICAL EXAMINATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section V: Physical Examination - Items 1-17 must be performed and completed by the Medical Practitioner.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Body Mass Index (BMI):

 

 

 

 

 

 

 

 

 

Height

 

 

 

Weight

 

 

 

 

 

 

Pulse

 

 

 

Blood

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(inches only):

 

 

 

(lbs):

 

 

 

 

 

 

Resting:

 

 

 

Pressure:

 

 

 

 

 

 

(For BMI > 40 refer to Section VIII)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please make comments in the space provided on any item indicated as an "abnormal" system/organ.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Item

 

Normal

Abnormal

 

 

Item

 

 

 

 

 

Normal

Abnormal

 

Item

 

Normal

Abnormal

1.

Head, Face, Neck, Scalp

 

 

 

 

 

 

 

 

 

 

 

7.

Upper/Lower Extremities

 

 

 

 

 

 

 

 

 

 

 

13. Skin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Eyes/Pupils/EOM

 

 

 

 

 

 

 

 

 

 

 

 

8.

Spine/Musculoskeletal

 

 

 

 

 

 

 

 

 

 

 

14. Neurologic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Mouth and Throat

 

 

 

 

 

 

 

 

 

 

 

 

9.

Vascular System

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. Mental Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Ears/Drums

 

 

 

 

 

 

 

 

 

 

 

 

10. Abdomen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Lungs and Chest

 

 

 

 

 

 

 

 

 

 

 

 

11. General/Systemic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. Hernia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Heart

 

 

 

 

 

 

 

 

 

 

 

 

12. Extremities/Digit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Medical Comments (Please Print)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL PRACTITIONER INITIALS:

 

 

 

 

 

DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CG-719K (04/17)

Previous Editions Obsolete

Page 6 of 10

Print Applicant Name:(Last, First, MI.)

 

Date of Birth: (MM/DD/YYYY)

 

 

 

Section VI: Vision - Must be performed by the Medical Practitioner, their medical staff or other qualified practitioner. Results must be reviewed by the Medical Practitioner. Additional guidance can be found at https://www.uscg.mil/hq/cg5/nvic/ pdf/2008/NVIC_04-08.pdf.

a. Visual Acuity

Distance Vision, Uncorrected: If correction required, Distance Vision Correctable To:

 

 

Field of Vision

Right:

20/

 

 

Right:

20/

 

 

 

 

Normal (the applicant's horizontal field of vision is

 

 

 

 

 

 

 

 

 

 

 

Left:

20/

 

 

Left:

20/

 

 

 

 

greater than or equal to 100 degrees).

 

 

 

 

 

 

 

 

 

 

 

 

Abnormal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Color Vision: The Medical Practitioner should assess the applicant's color vision sense using one of the following testing methodologies. The Medical Practitioner must indicate which test was utilized, and the number of errors obtained. In order to meet the standard, the applicant must demonstrate satisfactory color sense without the use of color enhancing lenses.

 

 

AOC (1965) - (6 or fewer errors on plates 1-15)

 

 

 

 

Ishihara pseudoisochromatic plates test, 14 plate (5 or less errors)

 

 

AOC-HRR (2nd Edition) - (No errors in test plates 7-11)

 

Ishihara pseudoisochromatic plates test, 24 plate (6 or less errors)

 

 

 

 

 

HRR PIP (4th Edition) - (No errors in test plates 5-10)

 

Ishihara pseudoisochromatic plates test, 38 plate (8 or less errors)

 

 

 

 

 

Richmond (2nd and 4th Edition) - (6 or fewer errors)

 

 

 

 

Farnsworth Lantern (colored lights) Test per instruction booklet

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Titmus Vision Tester/OPTEC 2000 - (No errors on 6 plates)

 

Dvorine (2nd Edition) pseudoisochromatic 15 plate test (6 or less errors)

 

 

 

 

 

OPTEC 900 (colored lights) Test per instruction booklet

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Farnsworth D-15 Hue Test (Engineer/radio officer/tankerman/MODU only)

Alternative Testing (attach evaluation/test results):

 

 

 

 

 

 

 

 

 

 

Formal ophthalmology/optometry color vision evaluation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other alternative test acceptable to the Coast Guard

 

 

 

 

 

 

 

 

 

Color Vision Testing Results:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Passed

 

Failed

Number of Errors:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section VII: Hearing - Must be performed by the Medical Practitioner, their medical staff or other qualified practitioner. Results must be reviewed by the Medical Practitioner.

An applicant with normal hearing by forced whispered voice > 5 feet with or without hearing aids does not need to complete either the audiometer test or the functional speech discrimination test.

 

Normal Hearing

 

Abnormal Hearing

 

Hearing Aid Required

(a) If hearing is abnormal, then perform either a functional speech discrimination test at 65dB or an audiogram documenting thresholds and averages as indicated below. Both aided and unaided values should be recorded for applicants requiring hearing aids.

(b) All applicants with an unaided threshold > 30dB in the better ear should have functional speech discrimination testing performed at 65dB.

(c) Refer to Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials which can be found at https://www.uscg.mil/hq/cg5/nvic/pdf/2008/ NVIC_04-08.pdf for further guidance. Report any additional information or comments in Section IX.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Audiometer

 

 

 

 

 

Functional Speech

 

 

 

 

 

 

 

Threshold Value

 

 

 

 

Discrimination Test @ 65dB, if required by

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

instruction (b) above

 

 

 

 

 

 

500Hz

1,000Hz

2,000Hz

3,000Hz

Average

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Right Ear (Unaided)

 

 

 

 

 

 

 

 

 

 

Right Ear (Unaided):

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Left Ear (Unaided)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Left Ear (Unaided):

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Right Ear (Aided)

 

 

 

 

 

 

 

 

 

 

Right Ear (Aided):

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Left Ear (Aided)

 

 

 

 

 

 

 

 

 

 

Left Ear (Aided):

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL PRACTITIONER INITIALS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CG-719K (04/17)

Previous Editions Obsolete

Page 7 of 10

Print Applicant Name:(Last, First, MI.)

Date of Birth: (MM/DD/YYYY)

Section VIII: Demonstration of Physical Ability - To be completed by the Medical Practitioner

LISTS OF TASKS CONSIDERED NECESSARY FOR PERFORMING ORDINARY AND EMERGENCY RESPONSE SHIPBOARD FUNCTIONS

Shipboard Tasks, Function, Event, or

Related Physical Ability

The Examiner Should Be Satisfied That The Applicant:

Condition

 

 

 

 

 

Routine movement on slippery, uneven,

Maintain balance (equilibrium)

Has no disturbance in sense of balance

and unstable surfaces

 

 

 

 

 

Routine access between levels

Climb up and down vertical ladders and stairways

Is able, without assistance, to climb up and down vertical ladders

and stairways

 

 

 

 

 

Routine movement between spaces and

Step over high doorsills and coamings, and move

Is able, without assistance, to step over a doorsill or coaming of 24

inches (600 millimeters) in height. Able to move through a

compartments

through restricted accesses

restricted opening of 24 x 24 inches

 

 

 

 

 

 

 

Is able, without assistance, to open and close watertight doors that

Open and close watertight doors, hand

Manipulate mechanical devices using manual and digital

may weigh up to 55 pounds (25 kilograms); should be able to

move hands/arms to open and close valve wheels in vertical and

cranking systems, open/close valve

dexterity, and strength

horizontal directions; rotate wrists to turn handles; able to reach

 

 

 

 

above shoulder height

 

 

 

 

 

Is able, without assistance, to lift at least a 40 pound (18.1

Handle ship's stores

Lift, pull, push, carry a load

kilograms) load off the ground, and to carry, push, or pull the same

 

 

load

 

 

 

 

Crouch (lowering height by bending knees); kneel

 

General vessel maintenance

(placing knees on ground); stoop (lowering height by

Is able, without assistance, to grasp, lift, and manipulate various

bending at the waist); use hand tools such as span-ners,

common shipboard tools

 

 

valve wrenches, hammers, screwdrivers, pliers

 

 

 

 

Emergency response procedures

Crawl (ability to move body using hands and knees); feel

Is able, without assistance, to crouch, kneel, and crawl, and to

including escape from smoke-filled

(ability to handle or touch to examine or determine

distinguish differences in texture and temperature by feel

spaces

differences in texture and temperature)

 

 

 

 

Stand a routine watch

Stand a routine watch

Is able, without assistance, to intermittently stand on feet for up to

four hours with minimal rest periods

 

 

 

 

 

React to visual alarms and instructions,

Distinguish an object or shape at a certain distance

Fulfills the eyesight standards for the merchant mariner credential

emergency response procedures

 

 

 

 

 

React to audible alarms and

Hear a specified decibel (dB) sound at a specified

 

instructions, emergency response

Fulfills the hearing standards for the merchant mariner credential

frequency

procedures

 

 

 

 

 

 

Make verbal reports or call attention to

Describe immediate surroundings and activities, and

Is capable of normal conversation

suspicious or emergency conditions

pronounce words clearly

 

 

 

 

 

Be able to carry and handle fire hoses and fire

Is able, without assistance, to pull an uncharged 1.5 inch diameter,

Participate in fire fighting activities

50' fire hose with nozzle to full extension, and to lift a charged 1.5

extinguishers

 

inch diameter fire hose to fire fighting position

 

 

 

 

 

 

 

Has the agility, strength, and range of motion to put on a personal

Abandon ship

Use survival equipment

flotation device and exposure suit without assistance from another

 

 

individual

 

 

 

1.The Medical Practitioner should indicate whether the applicant can meet the guidelines listed in the table above. If the Medical Practitioner doubts the applicant's ability to meet the guidelines contained within this table, and for all applicants with a Body Mass Index (BMI) of 40 or higher, the practitioner should require that the applicant demonstrate the ability to meet the guidelines contained within this table. This does not mean, for example, that the applicant must actually don an exposure suit, pull an unchanged 1.5 inch diameter 50' fire hose with nozzle to full extension, or lift a charged 1.5 inch diameter fire hose to firefighting position. Rather, the Medical Practitioner may utilize alternative measures to satisfy themselves that the applicant possesses the ability to meet the guidelines in the third column. A description of the methods utilized by the Medical Practitioner should be reported in the Comments section provided below.

2.All practical demonstrations should be performed by the applicant without assistance. Any prosthesis normally worn by the applicant, and any other aid devices, may be used by the applicant in all practical demonstrations except when the use of such items would prevent the proper wearing of mandated personal protection equipment (PPE).

3.If the Medical Practitioner is unable to conduct the practical demonstration, the applicant should be referred to a competent evaluator of physical ability. The Coast Guard recognizes that not all medical practitioners will have the equipment necessary to test all of the tasks as listed. Equivalent alternate testing methodologies may be used. For further information, check the Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials which can be found at https://www.uscg. mil/hq/cg5/nvic/pdf/2008/NVIC_04-08.pdf.

4.If the applicant is unable to perform all of the functions listed in the table above, the Medical Practitioner should provide information on the degree or the severity of the applicant's inability to meet the standards. The results of any practical demonstration or attendant physical evaluation should be recorded in the Comments section provided below.

Physical Ability

 

 

Applicant has the physical strength, agility, and flexibility to

 

Applicant does NOT have the physical strength, agility, and flexibility

 

 

Results:

 

 

perform all of the items listed in the physical ability table.

 

to perform all of the items listed in the physical ability table.

 

 

 

 

 

 

 

 

 

 

COMMENTS:

 

 

 

 

 

 

 

 

 

 

 

 

(Please Print)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL PRACTITIONER INITIALS:

DATE:

CG-719K (04/17)

Previous Editions Obsolete

Page 8 of 10

Print Applicant Name:(Last, First, MI.)

Date of Birth: (MM/DD/YYYY)

Section IX: Summary - To be completed by the Medical Practitioner

a. Applicant proof of identity provided:

 

Yes

 

No

b. Certification recommendation: Recommended Not Recommended Needs Further Review

c. Assessment: 1. Preliminary screening indicates that the applicant is not at high risk of having a condition(s) that poses a significant risk of sudden incapacita-

tion or debilitating complication, to include, uncontrolled obstructive sleep apnea, diabetes mellitus or coronary

 

Yes

 

No

 

NEEDS FURTHER REVIEW

artery disease:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OR,

 

 

 

 

 

 

2. (Entry-level, only) - To the best of my knowledge, mariner applicant is free from any medical condition likely to be aggravated by service at sea or to render the

seafarer unfit for such service or to endanger the health of other persons on board.

 

Yes

 

No

 

NEEDS FURTHER REVIEW

 

 

 

 

 

 

 

d. Discussion: Please discuss any conditions subject to further review identified in Section III(b) or any other concerns. Please print or type.

e. Medical Practitioner: My signature attests, subject to criminal prosecution under 18 USC § 1001, that all information reported by me is true and correct to the best of my knowledge and that I have not knowingly omitted or falsified any material information relevant to this form. My signature also attests that I have fully evaluated all examination tests and results submitted in support of this application.

Last Name

First Name

M.I.

License Number

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

Date (MM/DD/YYYY)

 

 

 

 

 

 

 

 

Office Street Address

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

Phone Number

MD

 

DO

 

PA

 

NP

 

(Place office address stamp here)

Section X: Application Certification - To be completed by the Applicant

My signature below attests, subject to prosecution under 18 USC § 1001, that all information provided by me on this form is complete and true to the best of my knowledge, and I agree that it is to be considered part of the basis for issuance of any medical certificate to me. I have not knowingly omitted any material information relevant to this form. I have also read and understand the Privacy Notice that accompanies this form.

Signature of ApplicantDate (MM/DD/YYYY)

PRIVACY NOTICE

Authority: 14 U.S.C. 632; 46 U.S.C. 2103, 7101, 7302, 7502, 46 C.F.R. 10.301

Purpose: The information is collected by the Coast Guard to determine whether an applicant meets the regulatory standards for issuance of a U.S. Merchant Mariner Credential (MMC). The Coast Guard evaluates an applicant's qualifications to determine compliance with the national and international requirements for issuance of the MMC, any endorsement within the MMC, and medical certificate.

Routine Uses: The information is used by authorized Coast Guard personnel who have a need for the record to determine whether an applicant is a safe and suitable person and qualifies for the MMC, any endorsement within the MMC, and medical certificate. In addition, the Coast Guard uses this information to maintain and update records of merchant mariner documentation transactions. The information will not be shared outside of DHS except in accordance with the provisions of DHS/USCG-030 Merchant Seamen's Records System of Records, 74 FR 30308 (June 25, 2009).

Disclosure: Furnishing this information (including your SSN) is voluntary; however, failure to furnish the requested information may result in the non-issuance of the MMC, any endorsement within the MMC, and medical certificate.

An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The United States Coast Guard estimates that the average burden for this form is 18 minutes. You may submit any comments concerning the accuracy of this burden or any suggestions for reducing the burden to the Chief, Office of Merchant Mariner Credentialing, 2703 Martin Luther King, Jr. Ave, S.E., STOP 7509, Washington, D.C., 20593-7509.

CG-719K (04/17)

Previous Editions Obsolete

Page 9 of 10

Print Applicant Name:(Last, First, MI.)

Date of Birth: (MM/DD/YYYY)

Section XI: (Optional) Applicant Consent - To be completed by the Applicant

Declined

 

 

 

 

 

 

 

 

a. CONSENT FOR MEDICAL PRACTITIONER TO RELEASE INFORMATION TO THE COAST GUARD:

My signature below authorizes the Medical Practitioner, who has signed the certification on page 9 of this form, to release to, or discuss with authorized Coast Guard personnel, any pertinent information in his/her possession regarding any physical or medical condition that may require review by the Coast Guard prior to determining whether the Coast Guard should issue a merchant mariner medical certificate.

I understand that this authorization is voluntary. I also understand that failure to provide authorization could affect the Coast Guard's ability to make a timely determination as to whether the Coast Guard should issue me a merchant mariner medical certificate. This authorization will remain in effect until the Coast Guard determines whether to issue me the requested merchant mariner medical certificate for maritime service, but no longer than one year.

I have read and understand the following statement about my rights:

UI may revoke this authorization at any time prior to its expiration date by notifying the verifying medical practitioner in writing, but the revocation will not have any effect on any actions taken before they received the notification.

UUpon request, I may see or copy the information described in this release.

UI am not required to sign this release to receive my medical evaluation.

Signature of Applicant

 

Date (MM/DD/YYYY)

 

 

 

 

 

 

 

 

b. CONSENT FOR COAST GUARD TO RELEASE INFORMATION TO A THIRD PARTY:

My signature authorizes the Coast Guard to share my medical information with the third party indicated below. I understand that I may revoke this authorization at any time prior to its expiration date by notifying the Coast Guard in writing.

Please provide the Name of the Organization or Third Party, Address, and Phone Number. Additional Third Party Authorization information may be attached separately.

Name of Organization or Third Party

Organization Point of Contact (if applicable)

Phone Number

 

 

 

 

 

 

 

 

Street Address

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Applicant

 

 

Date (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. CONSENT FOR THIRD PARTY TO ACT ON MY BEHALF:

My signature authorizes the following third party to act on my behalf in all matters pertaining to the processing of my current application for a medical certificate. This means that the Coast Guard will share my medical information and correspond with the third party, and it means that the third party can request agency action on my behalf, and receive my medical certificate.

I understand that I may revoke this authorization at any time prior to its expiration date by notifying the Coast Guard in writing.

Please provide the Name of the Organization or Third Party, Address, and Phone Number. Additional Third Party Authorization information may be attached separately.

Name of Organization or Third Party

Organization Point of Contact (if applicable)

Phone Number

 

 

 

 

 

 

 

 

Street Address

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Applicant

 

 

Date (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CG-719K (04/17)

Previous Editions Obsolete

Page 10 of 10

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