Embarking on a career at sea requires more than just ambition and training; it involves rigorous health assessments to ensure the safety of the individual and those onboard. The C105B form, a crucial document within the maritime and shipping industry, serves as a bridge between health regulations and maritime safety, embodying the standards set by the International Labour Organization (ILO), the World Health Organization (WHO), the International Convention on Standards of Training, Certification, and Watchkeeping for Seafarers (STCW), and the Maritime Labour Convention (MLC). This medical certificate meticulously documents an individual's health status, declaring their fitness for various duties at sea - from lookout duties to engine service - based on a comprehensive evaluation that includes the examinee’s personal declaration, clinical examination, and the results of diagnostic tests. Key aspects covered in the form are visual and physical fitness for duty, with special attention to specific requirements like visual aids if necessary, and the results of chest X-rays and stool tests to ensure no underlying conditions could hinder the person’s ability to serve. Restrictions can be detailed, tailoring the certificate to suit different roles on a ship, areas of operation, or types of vessels. With a validity of two years, this form not only underscores the importance of maintaining health standards in the maritime profession but also highlights the ongoing commitment to safety and efficiency in this global industry.
| Question | Answer |
|---|---|
| Form Name | Form C105B |
| Form Length | 1 pages |
| Fillable? | Yes |
| Fillable fields | 41 |
| Avg. time to fill out | 8 min 31 sec |
| Other names | medical certificate for service at sea, certificate of service for petrus motlonye, mlc certificate format, dg shipping medical certificate format |
MEDICAL CERTIFICATE FOR SERVICE AT SEA
(In accordance with ILO /WHO D.2/ 1997 & STCW Reg I/9 and MLC Reg 1.2)
1
Family Name
Given Names
Date of birth (day/month/year)
Sex:
Male
Female
Home address
Passport No./Discharge Book No.:
Nationality :
I have evaluated the above named examinee according to ____________________________________
(national law, regulation or other requirement)
On the basis of the examinee’s personal declaration, my clinical examination and diagnostic test results recorded on the medical examination form, I declare the examinee:
Fit for |
|
Not fit for |
|
|
|
Deck service |
Engine service |
Catering service |
Other services |
Fit |
|
|
|
|
Unfit |
|
|
|
|
Without restrictions |
|
With restrictions |
|
|
Visual aid required |
Yes |
No |
|
|
Chest |
|
normal |
not performed |
|
Bacteriological stool test*1 |
negative |
not performed |
||
Parasitical stool test*2 |
|
negative |
not performed |
|
Vaccination records
satisfactory
to be renewed
Describe any restrictions (e.g., specific position, type of ship, trade area):
Place of examination: ___________________ Date (day/month/year) _____/_____/_____
Official stamp (also print name of medical examiner):
Signature of medical examiner: ___________________
Authorised by: _________________________________ (competent authority)
I acknowledge that I have been advised of the content of the medical examination form.
Examinee’s signature: ___________________
(To be signed in the presence of the medical examiner)
MEDICAL EXAMINATION IS VALID 2 YEARS UNTIL Date (day/month/year) __ /_ _/__
Form C105B
Version: 2 Issued: 10/05
Revision: 1 Issued: 02/12
Page 1 of 1