B.06.05 Attachment 10 - U.S Coast Guard License CG-719K.pdf

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DEPARTMENT OF HOMELAND SECURITY OMB No. 1625-0040 U.S. Coast Guard Exp. Date: 03/31/2021

APPLICATION FOR MEDICAL CERTIFICATE (FORM CG-719K)

------ 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).

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 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.

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

DATE:MEDICAL PRACTITIONER INITIALS:

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.

Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)

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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

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.

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 V: Physical Examination - Items 1-17; To be performed and 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 VIII: Demonstration of Physical Ability - To be completed by the Medical Practitioner

DATE:MEDICAL PRACTITIONER INITIALS:

Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)

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 IV: Medications - To be completed by the Applicant and reviewed by the Medical Practitioner https://www.uscg.mil/nmc/credentials/forms/3rd_party_authorization_med_cert.pdf

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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)

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

Zip CodeStateCity

Street Address Home Address (PO Box NOT acceptable)

Delivery/Mailing Address, if different (PO Box acceptable)

Zip CodeStateCity

Primary Phone Number

Alternate Phone Number

E-mail Address

Other

Street Address

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

Deck STCWEngine Food Handler

U.S. Registered Pilot (Great Lakes Pilotage)

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.

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

Yes No N/AIs the applicant free from communicable disease?

DEPARTMENT OF HOMELAND SECURITY OMB No. 1625-0040 U.S. Coast Guard Exp. Date: 03/31/2021

APPLICATION FOR MEDICAL CERTIFCATE (FORM CG-719K)

DATE:MEDICAL PRACTITIONER INITIALS:

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

Entry-level with lookout duties

Other (Please explain):

FemaleMale

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

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.

I have a medical waiver (MW): If YES, provide a copy to the Medical Practitioner, and mark the MW box below.Yes No

DATE:

Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)

MEDICAL PRACTITIONER INITIALS:

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?

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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).

LimitationsStatus

TreatmentCondition

DATE:MEDICAL PRACTITIONER INITIALS:

AttachedDate of onset or diagnosis (mm/dd/yyyy)Item #

LimitationsStatus

TreatmentCondition

AttachedDate of onset or diagnosis (mm/dd/yyyy)Item #

LimitationsStatus

TreatmentCondition

AttachedDate of onset or diagnosis (mm/dd/yyyy)Item #

LimitationsStatus

TreatmentCondition

AttachedDate of onset or diagnosis (mm/dd/yyyy)Item #

LimitationsStatus

TreatmentCondition

AttachedDate of onset or diagnosis (mm/dd/yyyy)Item #

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

DATE:

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

MEDICATION DOSE FREQUENCY CONDITION MEDICAL PRACTITIONER COMMENTS (Duration of Use/Side Effects)

Applicants Must Report

1. All medications (Prescription or Nonprescription), dietary supplements, and vitamins; that were filled, or refilled, and/or taken within 30 days prior to the date the applicant signs the CG-719K; and

2. All medications (Prescription or Nonprescription), dietary supplements, and vitamins that were used for a period of 30 or more days within the last 90 days prior to the date the applicant signs the CG-719K.

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

Height (inches only):

Pulse Resting:

Weight (lbs):

Blood Pressure:

Body Mass Index (BMI):

(For BMI > 40 refer to Section VIII)

Additional Medical Comments (Please Print)

Medical Practitioner

1. Medical Practitioner must verify applicants medications and information listed in the table below.

2. Medical Practitioner comments should include the approximate length of time the applicant has taken the medication and address the presence or absence of any side effects.

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

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

MEDICAL PRACTITIONER INITIALS:

If YES, provide the information requested in the blocks below.Yes NoDo you currently use any medication (prescription or nonprescription)?

REPORT OF MEDICAL EXAMINATION

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.

Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)

1. Head, Face, Neck, Scalp

6. Heart

5. Lungs and Chest

4. Ears/Drums

3. Mouth and Throat

2. Eyes/Pupils/EOM

Item Normal

7. Upper/Lower Extremities

12. Extremities/Digit

11. General/Systemic

10. Abdomen

9. Vascular System

8. Spine/Musculoskeletal

Item Normal Abnormal

13. Skin

16. Hernia

15. Mental Status

14. Neurologic

Item Normal Abnormal

YesNo

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

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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

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.

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.

(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.

Distance Vision, Uncorrected:

Right: 20/

Left: 20/

If correction required, Distance Vision Correctable To:

Right: 20/

Left: 20/

Field of Vision

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

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

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

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

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

OPTEC 900 (colored lights) Test per instruction booklet

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

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

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

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

Farnsworth Lantern (colored lights) Test per instruction booklet

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

Passed Failed

Color Vision Testing Results:

Number of Errors:

Normal Hearing Abnormal Hearing Hearing Aid Required

500Hz 1,000Hz 2,000Hz 3,000Hz Average

Right Ear (Unaided)

Left Ear (Unaided)

Right Ear (Aided)

Left Ear (Aided)

Audiometer Threshold Value

Functional Speech Discrimination Test @ 65dB, if required by instruction (b) above

Right Ear (Unaided):

Left Ear (Unaided):

Right Ear (Aided):

Left Ear (Aided):

Normal (the applicant's horizontal field of vision is greater than or equal to 100 degrees).

Abnormal

DATE:

Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)

MEDICAL PRACTITIONER INITIALS:

Alternative Testing (attach evaluation/test results):

Formal ophthalmology/optometry color vision evaluation

Other alternative test acceptable to the Coast Guard

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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.

Applicant has the physical strength, agility, and flexibility to perform all of the items listed in the physical ability table.

Applicant does NOT have the physical strength, agility, and flexibility to perform all of the items listed in the physical ability table.

Physical Ability Results:

COMMENTS:

(Please Print)

LISTS OF TASKS CONSIDERED NECESSARY FOR PERFORMING ORDINARY AND EMERGENCY RESPONSE SHIPBOARD FUNCTIONS Shipboard Tasks, Function, Event, or

Condition Related Physical Ability The Examiner Should Be Satisfied That The Applicant:

Routine movement on slippery, uneven, and unstable surfaces Maintain balance (equilibrium) Has no disturbance in sense of balance

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 compartments

Step over high doorsills and coamings, and move through restricted accesses

Is able, without assistance, to step over a doorsill or coaming of 24 inches (600 millimeters) in height. Able to move through a restricted opening of 24 x 24 inches

Open and close watertight doors, hand cranking systems, open/close valve

Manipulate mechanical devices using manual and digital dexterity, and strength

Is able, without assistance, to open and close watertight doors that may weigh up to 55 pounds (25 kilograms); should be able to move hands/arms to open and close valve wheels in vertical and horizontal directions; rotate wrists to turn handles; able to reach above shoulder height

Handle ship's stores Lift, pull, push, carry a load Is able, without assistance, to lift at least a 40 pound (18.1 kilograms) load off the ground, and to carry, push, or pull the same load

General vessel maintenance

Crouch (lowering height by bending knees); kneel (placing knees on ground); stoop (lowering height by bending at the waist); use hand tools such as span-ners, valve wrenches, hammers, screwdrivers, pliers

Is able, without assistance, to grasp, lift, and manipulate various common shipboard tools

Emergency response procedures including escape from smoke-filled spaces

Crawl (ability to move body using hands and knees); feel (ability to handle or touch to examine or determine differences in texture and temperature)

Is able, without assistance, to crouch, kneel, and crawl, and to distinguish differences in texture and temperature by feel

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, emergency response procedures Distinguish an object or shape at a certain distance Fulfills the eyesight standards for the merchant mariner credential

React to audible alarms and instructions, emergency response procedures

Hear a specified decibel (dB) sound at a specified frequency Fulfills the hearing standards for the merchant mariner credential

Make verbal reports or call attention to suspicious or emergency conditions

Describe immediate surroundings and activities, and pronounce words clearly Is capable of normal conversation

Participate in fire fighting activities Be able to carry and handle fire hoses and fire extinguishers

Is able, without assistance, to pull an uncharged 1.5 inch diameter, 50' fire hose with nozzle to full extension, and to lift a charged 1.5 inch diameter fire hose to fire fighting position

Abandon ship Use survival equipment Has the agility, strength, and range of motion to put on a personal flotation device and exposure suit without assistance from another individual

Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)

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

DATE:MEDICAL PRACTITIONER INITIALS:

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

NoYesa. Applicant proof of identity provided:

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.

Zip CodeStateCity

Office Street Address

M.I.First NameLast Name

Date (MM/DD/YYYY)Signature

MD PA NP

License Number State

(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 Applicant Date (MM/DD/YYYY)

Phone Number

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 artery disease:

NoYes Needs Further Review

Recommended Not Recommended Needs Further Reviewb. Certification recommendation:

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.

PRIVACY NOTICE

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.

Date of Birth: (MM/DD/YYYY)Print Applicant Name:(Last, First, MI.)

DO

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

CG-719K (04/17) Previous Editions Obsolete Page 10 of 10

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:

u I 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.

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

u I 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.

Signature of Applicant Date (MM/DD/YYYY)

Name of Organization or Third Party

Organization Point of Contact (if applicable) Phone Number

Street Address

Signature of Applicant Date (MM/DD/YYYY)

StateCity Zip Code

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

StateCity Zip Code

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

CG-719K (04/17)

CG-719K (04/17)

Previous Editions Obsolete Page of DEPARTMENT OF HOMELAND SECURITY OMB No. 1625-0040 U.S. Coast Guard Exp. Date: 03/31/2021

APPLICATION FOR MEDICAL CERTIFICATE (FORM CG-719K)

------ 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).

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.

46 CFR 10.107

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.

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

Privacy Act Statement 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 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.

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 V: Physical Examination - Items 1-17; To be performed and 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 VIII: Demonstration of Physical Ability - To be completed 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 IV: Medications - To be completed by the Applicant and reviewed by the Medical Practitioner 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) Please indicate best method(s) of contact by checking the appropriate box(es).

Zip Code State City Street Address Zip Code State City Street Address Endorsement Held or Sought (Check all that apply or the Coast Guard will not accept the application):

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…