Republic of Latvia

Cabinet
Regulation No. 273
Adopted 3 June 2014

Latvijas
Jūras administrācija

Lesser State coat of arms

Maritime Administration
of Latvia

JŪRNIEKA MEDICĪNISKAIS SERTIFIKĀTS Nr.
SEAFARER'S MEDICAL CERTIFICATE No.

Vīrietis Sieviete
(Male) (Female)

Valsts akciju sabiedrības "Latvijas Jūras administrācija" Jūrnieku reģistra atzītā jūrnieku ārsta paraksts un zīmogs
(Signature and stamp of medical practitioner recognized by the Registry of Seamen of the State stock company "Maritime Administration of Latvia")

Z. v.

SVARĪGA INFORMĀCIJA
IMPORTANT INFORMATION

1. Parakstot šo medicīnisko sertifikātu, jūrnieks apliecina, ka medicīniskās pārbaudes laikā jūrnieku ārstam ir sniedzis patiesu informāciju par savu veselības stāvokli, ciktāl viņam tā ir zināma, un ir informēts par medicīniskā sertifikāta saturu.
(By signing this medical certificate a seafarer is confirming that he (she) has provided true information to the best of his (her) knowledge about the state of his (her) health to the recognized medical practitioner and he (she) is informed of the content of the medical certificate.)

2. Strādājot uz kuģa, jūrnieka rīcībā jābūt medicīniskā sertifikāta oriģinālam, lai apliecinātu sava veselības stāvokļa atbilstību darbam uz kuģa. Nākamās veselības pārbaudes laikā šis medicīniskais sertifikāts ir jānodod jūrnieku ārstam, kurš veic veselības pārbaudi.
(A seafarer must retain the original of this certificate as evidence of medical fitness while serving on board of ship. This certificate must be surrendered to the recognized medical practitioner when attending next medical examination.)

3. Ja jūrnieks nepieciešamo redzes asumu var sasniegt tikai ar brillēm vai kontaktlēcām vai nepieciešamo dzirdes līmeni var sasniegt tikai ar dzirdes palīglīdzekļiem, jūrnieka pienākums ir izmantot minētos palīglīdzekļus darba laikā un uz kuģa glabāt attiecīgo palīglīdzekļu un to rezerves komplektu.
(If required visual acuity can only be achieved with glasses or contact lenses or required hearing capacity can only be achieved with hearing aids, a seafarer must use these aids while performing his (her) duties and keep on board of ship a spare set of those aids and their consumables.)

4. Ja pretendentam kuģa reisa laikā ir jālieto medikamenti, jūrnieku ārsts pretendentam izsniedz dokumentu par zāļu lietošanas nepieciešamību un zāļu aprakstu. Ja medikamenti satur narkotiskās un psihotropās vielas, dokumentu izsniedz saskaņā ar normatīvo aktu prasībām par narkotisko un psihotropo vielu un zāļu aprites kārtību. Minētais dokuments jūrniekam jāņem līdzi uz kuģa, lai, ja nepieciešams, to uzrādītu kompetentām amatpersonām.
(If a seafarer needs to take medication during service at sea, he (she) must carry on board of ship documentation for use of medication and description of the medication issued by the recognized medical practitioner to show it to any officials if necessary. If medication contains narcotic and psychotropic substances, the document must be issued in accordance with the statutory requirements of procedures for the legal trade of narcotic and psychotropic substances and medicinal products.)

5. Ja šī medicīniskā sertifikāta derīguma termiņa laikā jūrniekam ir iestājusies darbnespēja, ilgāka par 30 dienām, vai jūrnieks medicīnisku iemeslu dēļ ir repatriēts no kuģa, vai jūrniekam ir zināms, ka viņa veselības stāvokļa dēļ var tikt apdraudēta citu personu veselība vai drošība uz kuģa, vai jūrnieka veselības stāvoklis neatbilst prasībām, kas noteiktas darbam uz kuģa, viņa pienākums ir 15 dienu laikā no attiecīgās problēmas konstatēšanas brīža ziņot par to jūrnieku ārstam (vēlams - tam ārstam, kurš ir izsniedzis šo medicīnisko sertifikātu).
(If during validity of this medical certificate a seafarer has suffered more than 30 days incapacitation or seafarer has been repatriated from the ship due to medical reasons, or seafarer is aware that he (she) is no longer medically fit for duty or his (her) health condition may endanger health or safety of other persons on board, it is seafarer's responsibility to notify a recognized medical practitioner (preferably the one who issued this medical certificate) within 15 days from the occurrence of the mentioned cases.)

Z.v
Stamp

__________________________________________________________________________________________________________________________
(dd. mm. yyyy)

Passport No. ___________________________________ Identity card No. _____________________________________________

Medical examination of a person has been carried out in accordance with the procedures and criteria for the medical examination of a person who is planned to be enrolled or matriculated in a professional education programme after acquisition of which a document certifying qualification of the seafarer may be received laid down in Cabinet Regulation No. 273 of 3 June 2014, Regulations Regarding the Medical Fitness of Seafarers for Work on a Ship.

OPINION

The health condition of a person conforms / does not conform for work on a ship in the selected speciality(if it conforms - mark the corresponding speciality and delete the inapplicable ones; if it does not conform - delete all specialities):

ship navigation speciality (including deck rating speciality)

marine engineering or marine electrical automation speciality (including the speciality of an engine rating, an electro-technical rating, a refrigeration engineer, a fitter, a turner, and a welder)

__________________________________________________________________________________________________________________________
(dd. mm. yyyy)

___________________________________________________________________________

Vai jūs esat kādreiz saskāries ar kādu no norādītajām veselības problēmām?
(Have you ever had any of the following conditions?)

Veselības problēma
Condition

Jā
Yes

Nē
No

Veselības problēma
Condition

Jā
Yes

Nē
No

Jā
Yes

Nē
No

Ja uz kādu no jautājumiem esat atbildējis "jā", lūdzu, sniedziet papildinformāciju, norādot, ja iespējams, kad tas bija. Ja lietojat medikamentus, lūdzu, norādiet lietotos medikamentus, to lietošanas nolūku(-us) un lietoto devu(-as)

(If you answered "yes" to any of the above questions, please give details, including, if possible, when it was. If you are taking any medications, please list the medications taken, and the purpose(s) and dosage(s))

(atzītā jūrnieku ārsta vārds, uzvārds)

(name, surname of the recognized medical practitioner))

Bez palīglīdzekļiem (Unaided)

Ar palīglīdzekļiem (Aided)

Labā acs
(Right eye)

Kreisā acs
(Left eye)

Abas acis
(Binocular)

Labā acs
(Right eye)

Kreisā acs
(Left eye)

Abas acis
(Binocular)

Normāli
(Normal)

Nepilnīgi
(Defective)

Piezīmes, ja redzes lauki nepilnīgi
(Remarks, if visual fields are defective)

Runas balsī (Normal voice)

Čukstus balsī (Whisper)

Norma
(Normal)

Patoloģisks
(Abnormal)

Norma
(Normal)

Patoloģisks
(Abnormal)

Rezultāti (Results)

Pārbaude (Test)

Rezultāti (Results)

Klāja komandā
(Deck department)

Mašīntelpas komandā
(Engine department)

Ēdināšanas komandā
(Catering department)

Citā komandā
(Other department)

Z. v.

STCW Convention regulation

Category of seafarer

Distance vision aided¹

Near/intermediate vision

Colour vision³

Visual fields⁴

Night blindness⁴

Diplopia (double vision)⁴

one eye

other eye

both eyes together, aided or unaided

0.5²

0.5

See Note 5

ICD (diagnostic codes)

Condition

(justification for criteria)

Health condition is incompatible with reliable performance of routine and emergency duties safely or effectively - expected to be temporary (T), expected to be

permanent (P)

Able to perform some but not all duties or to work in some but not all waters (R). Increased frequency of surveillance needed (L)

Able to perform all duties worldwide in designated position/within designated department

I. Infections

Transmission to others, recurrence

Catering department: fitness decision to be based on specialist advice - bacteriological clearance may be required

Transmission to others, recurrence

P - Relapse or severe residual damage

Acute impairment, recurrence

P - Untreatable impairing late complications

Transmissible by food or water contamination

Transmissible by contact with blood or other bodily fluids. Possibility of permanent liver impairment and liver cancer

P - Persistent liver impairment with symptoms affecting safe work at sea or with likelihood of complications

Case-by-case decision-making based on duties and voyage patterns

Transmissible by contact with blood or other bodily fluids.

Progression to HIV-associated diseases or AIDS

of > 350 or when treatment changed and tolerance of new medication uncertain

P - Non-reversible impairing HIV-associated diseases. Continuing impairing effects of medication

(Not listed separately)

Personal impairment, infection of others

P - If continuing likelihood of repeated incapacity or infectious recurrences

II. Cancers

Recurrence - especially acute complications, e.g. harm to self from bleeding and

to others from seizures

P - Continuing impairment with symptoms affecting safe work at sea or with high likelihood of recurrence

R - Restricted to near coastal waters if any continuing impairment does not interfere with essential duties and any recurrence is unlikely to require emergency medical treatment

III. Blood disorders

Reduced exercise tolerance. Episodic red cell breakdown

P - Severe recurrent or continuing anaemia or impairing symptoms from red cell breakdown that are untreatable

Increased susceptibility to certain infections

(Not listed separately)

Varied recurrence of abnormal bleeding and also possibly reduced exercise tolerance or low resistance to infections

P - Chronic coagulation disorders

IV. Endocrine and metabolic

Acute impairment from hypoglycaemia. Complications from loss of blood glucose control Increased likelihood of visual, neurological and cardiac problems

P - If poorly controlled or not compliant with treatment. History of hypoglycaemia or loss of hypoglycaemic awareness. Impairing complications of diabetes

Progression to insulin use, increased likelihood of visual, neurological and cardiac problems Increased likelihood of visual, neurological and cardiac problems

R - Near coastal waters, no solo watch keeping if minor side effects from medication. Especially when using sulphonylureas

L - Time limited if compliance poor or medication needs frequent review. Check diet, weight and vascular risk factor control

Progression to insulin use, increased likelihood of visual, neurological and cardiac problems

L - Time limited when stabilized, if compliance poor. Check diet, weight and vascular risk factor control

Accident to self, reduced mobility and exercise tolerance for routine and emergency duties. Increased likelihood of diabetes, arterial diseases and arthritis

P - If duties cannot be performed in emergency situations, capability or exercise test performance is poor with failure to achieve improvements.

Note. Body mass index is a useful indicator of when additional assessment is needed. National norms of this indicator may vary, therefore it should not form the sole basis for decisions on capability

(Not listed separately)

Thyroid, adrenal (including Addison's disease), pituitary, ovaries, testes diseases.

Likelihood of recurrence or complications

P - If continuing impairment, need for frequent adjustment of therapy/medication or increased likelihood of major complications

V. Mental, cognitive and behavioural disorders

Recurrence, accidents, erratic behaviour/safety performance

P - If persistent or there is co- morbidity likely to progress or recur while at sea

Recurrence, accidents, erratic behaviour/safety performance

P - If persistent or there is co- morbidity likely to progress or recur while at sea

- treating physician reports successful participation in rehabilitation program; and

- evidence of completion of unannounced/

random program of drug screening for at least three months with no positives and at least three negatives; and

- continuing participation in drug screening program

Recurrence leading to changes to perception/cognition, accidents, erratic and unsafe behaviour

T - Until investigated and stabilized and criteria for fitness met. At least three months after episode

Following single episode without provoking factors or more than one episode with or without provoking factors:

T - Until investigated and stabilized and conditions for fitness met. At least two years since last episode

P - More than three episodes or continuing likelihood of recurrence. Criteria for fitness with or without restrictions are not met

- the seafarer has insight;

- is compliant with treatment; and

- has no adverse effects from medication

R, L - Time limited, restricted to near coastal waters and not to work as master in charge of vessel or without close supervision and continuing medical monitoring, provided that:

- the seafarer has insight;

- is compliant with treatment; and

- has no impairing adverse effects from medication

Case-by-case assessment to exclude likelihood of recurrence, at least five years since end of episode if no further episodes; no residual symptoms; and no medication needed during last two years

Recurrence, reduced performance, especially in emergencies

P - Persistent or recurrent work disability

- good functional recovery;

- insight;

- is fully compliant with treatment;

- has no impairing adverse effects from medication;

- a low likelihood of recurrence

Recurrence, reduced performance, especially in emergencies

P - Persistent or recurrent work disability

(Not listed separately)

Impairment of performance and reliability and impact on relationships

VI. Diseases of the nervous system

Harm to ship, others and self from seizures

T - While under investigation and for one year after seizure

Non-watch-keeping duties in near coastal waters

Harm to ship, others and self from seizures

P - Recurrent fits, not controlled by medication

Harm to ship, others and self from seizures

P - Recurrent fits, not controlled by medication

Likelihood of disabling recurrences

Fatigue and episodes of sleep while working

P - Treatment unsuccessful or not being complied with

Six-monthly assessments of compliance based on CPAP machine recording

Fatigue and episodes of sleep while working

P - Treatment unsuccessful or not being complied with

(Not listed separately)

Recurrence/progression. Limitations on muscular power, balance, coordination and mobility

P - If limitations affect safe working or unable to meet physical capability requirements

Recurrence causing injury or loss of control

(a) simple faint;

(b) not a simple faint; unexplained disturbance, not recurrent and without any detected underlying cardiac, metabolic or neurological cause

T - Four weeks

(c) Disturbance; recurrent or with possible underlying cardiac, metabolic or neurological cause

T - With possible underlying cause that is not identified or treatable; for six months after event if no recurrences

T - With possible underlying cause or cause found and treated; for one month after successful treatment

(d) Disturbance of consciousness with features indicating a seizure (see G40-41).

P - For all of above if recurrent, incidents persist despite full, investigation and appropriate, treatment

R, L - Case-by-case decision, near coastal with no lone watch-keeping

With possible underlying cause but no treatable cause found; one year after event if no recurrences

With possible underlying cause found and treated; three months after successful treatment

With seizure markers - not applicable

Harm to ship, others and self from seizures.

Defects in cognitive, sensory or motor function.

Recurrence or complication of underlying condition

P - Continuing unfitness from underlying condition or injury or recurrent seizures

Conditional on continued compliance with any treatment and on periodic review, as recommended by specialist

Conditional on continued compliance with any treatment and on periodic review, as recommended by specialist

VII. Diseases of the eyes and ears

Future inability to meet vision standards, risk of recurrence

P - Inability to meet relevant vision standards or, if treated, increased likelihood of subsequent deterioration or impairing recurrence

L - If risk of progression foreseeable but unlikely and can be detected by regular monitoring

Recurrence,

risk as infection source in food handlers,

problems using hearing protection

P - If chronic discharge from ear in food handler

Consider effects of heat, humidity and hearing protection use in otitis externa

P - Inability to meet relevant hearing standards or, if treated, increased likelihood or subsequent deterioration or impairing recurrence

Inability to balance, causing loss of mobility and nausea

P - Frequent attacks leading to incapacity

R, L - If frequent specialist surveillance required

VIII. Cardiovascular system

(I34-39)

Likelihood of progression, limitations on exercise

P - If exercise tolerance limited or episodes of incapacity occur or if on anticoagulants or if permanent high likelihood of impairing event

L - If frequent surveillance is recommended

Increased likelihood of ischemic heart disease, eye and kidney damage and stroke. Possibility of acute hypertensive episode

P - If persistently >160 systolic or >100 diastolic mm Hg with or without treatment

Sudden loss of capability, exercise limitation. Problems of managing repeat cardiac event at sea

P - If criteria for issue of the medical certificate not met and further reduction of likelihood of recurrence improbable

R, L - If excess likelihood of recurrence is low.* Restricted to:

- no lone working or watch-keeping/lookout; and

- operations in near-coastal waters, unless working on vessel with ship's doctor

Issue six-month certificate initially and then annual certificate

R, L - If likelihood of recurrence is moderate* and asymptomatic. Able to meet the physical requirements or their normal and emergency duties:

- no lone working or watch-keeping/lookout; and

- operating within one hour of port, unless working on vessel with ship's doctor

Case-by-case assessment. Annual review

Acute impairment from recurrence.

Reduced exercise tolerance.

Pacemaker/ICD activity may be affected by strong electric fields

P - If disabling symptoms present or excess likelihood of impairment from recurrence, including ICD implant

R - Restrictions on solo duties or for distant waters if low* likelihood of acute impairment from recurrence or foreseeable requirement for access to specialist care

Surveillance and treatment regime to be specified. If pacemaker fitted, duration of certificate to coincide with pacemaker surveillance

Increased likelihood of recurrence, sudden loss of capability, mobility limitation. Liable to develop other circulatory disease

P - If residual symptoms interfere with duties or there is significant excess likelihood of recurrence

Annual assessment

Likelihood of other circulatory disease causing sudden loss of capability.

Reduced exercise tolerance.

P - If incapable of performing duties

P - Consider if recurrent events or on permanent anticoagulants

(Not listed separately)

Likelihood of recurrence, sudden loss of capability, exercise limitation

P - If impairing symptoms or likelihood of impairment from recurrence

IX. Respiratory system

(J30-39)

Impairing for individual. May recur. Transmission of infection to food/other crew in some conditions

P - If impairing and recurrent

Reduced exercise tolerance and impairing symptoms

P - If repeated severe recurrences or if general fitness standards cannot be met or if impairing shortness of breath

Unpredictable episodes of severe breathlessness

In person under age 20 with hospital admission or oral steroid use in last three years

P - If foreseeable likelihood of rapid life-threatening asthma attack while at sea or history of uncontrolled asthma, i.e. history of multiple hospital admissions

- history of moderate** adult asthma, with good control with inhalers and no episodes requiring hospital admission or oral steroid use in last two years;

- history of mild asthma;

- exercise-induced asthma that requires regular treatment

Over age 20: if history of mild** or exercise-induced** asthma and no requirements for continuing regular treatment

Acute impairment from recurrence

P - After recurrent episodes unless pleurectomy or pleurodesis performed

Post-surgery - based on advice of treating specialist

X. Digestive system

Acute pain from toothache. Recurrent mouth and gum infections

P - If excess likelihood of dental emergency remains after treatment completed or seafarer non-compliant with dental recommendations

Recurrence with pain, bleeding or perforation

P - If ulcer persists despite surgery and medication

Likelihood of strangulation

Instability of abdominal wall on bending and lifting

Consider implications of regular heavy whole-body physical effort

Consider implications of regular heavy whole-body physical effort

Consider implications of regular heavy whole-body physical effort

Reflux of stomach contents and acid causing heartburn, etc.

Impairment and pain

P - If severe or recurrent

Likelihood of episode causing pain and limiting activity

P - Consider if not treatable or recurrent

Liver failure. Bleeding oesophageal varices

P - If severe or complicated by ascites or oesophageal varicoses

Biliary colic from gallstones. Jaundice, liver failure

P - Advanced liver disease, recurrent or persistent impairing symptoms

Likelihood of recurrence

P - If recurrent or alcohol related, unless confirmed abstention

Impairment if control is lost - need for bags, etc. Potential problems during prolonged emergency

P - Poorly controlled

XI. Genito-urinary conditions

Renal failure, hypertension

Renal failure, hypertension

Pain from renal colic

P - Recurrent stone formation

urinary obstruction

Acute retention of urine

P - If not remediable

Impairment from pain or bleeding

Indicator of kidney or other diseases

P - Serious and non-remediable underlying cause - e.g. impairment of kidney function

R, L - When uncertainty about cause but no immediate problem

Limits to fluid regulation under extreme conditions if remaining kidney not fully functional

XII. Pregnancy

Complications, late limitations on mobility. Potential for harm to mother and child in the event of premature delivery at sea

XIII. Skin

Recurrence, transmission to others

P - Consider for catering staff with recurrent problems

Recurrence, sometimes occupational cause

R - As appropriate if aggravated by heat, or substances at work

XIV. Musculoskeletal

Pain and mobility limitation affecting normal or emergency duties. Possibility of infection or dislocation. Limited life of replacement joints

P - For advanced and severe cases.

Sudden limitation of mobility, with pain

Pain and mobility limitation affecting normal or emergency duties. Exacerbation of impairment

P - If recurrent or incapacitating

(Z97.1)

Mobility limitation affecting normal or emergency duties

XV. General

Limitations to communication ability

Likelihood of recurrence and increasing severity of response. Reduced ability to perform duties

P - If life-threatening response reasonably foreseeable

R - Where response is impairing rather than life-threatening, and reasonable adjustments can be made to reduce likelihood of recurrence

Possibility of rejection. Side effects of medication

P - Case-by-case assessment, with specialist advice

P - Consider at pre-sea medical if likely to prevent completion or limit scope of training

P - If permanently impairing

No.

Shipboard tasks, functions, events or conditions¹

Necessary physical fitness

The recognized medical practitioner performing the medical examination should make certain that²:

- on moving deck;

- between levels;

- between compartments

Climb up and down vertical ladders and stairways.

Step over coamings (e.g., Load Line Convention requires coamings to be 600 mm high).

Be able to open and close watertight doors

does not have any impairment or disease that prevents the applicant to perform necessary movements and physical activities.

The applicant is, without assistance⁴, able to:

- climb vertical ladders and stairways;

- step over high sills;

- manipulate door closing systems.

- use of hand tools;

- movement of ship's stores;

- overhead work;

- valve operation;

- standing a four-hour watch;

- working in confined spaces;

- responding to alarms, warnings and instructions;

- verbal communication

Lift, pull and carry a load (e.g., 18 kg).

Reach upwards.

Stand, walk and remain alert for an extended period of time.

Work in constricted spaces and move through restricted openings (e.g., SOLAS regulation II-1/3-6.5.1 requires openings in cargo spaces and emergency escapes to have the minimum dimensions of 600 mm x 600 mm).

Visually distinguish objects, shapes and signals.

Hear warnings and instructions.

Be able to give a clear spoken description

The applicant has ability to:

- work with arms raised;

- stand and walk for an extended period of time;

- enter confined spaces;

- fulfil eyesight standards (see Annex 4 to this Regulation);

- fulfil hearing standards pursuant to this Regulation and international guidelines;

- hold normal conversation.

- escape;

- fire-fighting;

- evacuation.

Escape from smoke-filled spaces.

Take part in fire-fighting duties, including use of breathing apparatus.

Take part in vessel evacuation procedures.

The applicant has ability to:

- don lifejacket or immersion suit;

- crawl;

- feel for differences in temperature;

- handle fire-fighting equipment;

- wear breathing apparatus (where required as part of duties).