Australian Government - Australian Maritime Safety Authority
SELF DECLARATION OF MEDICAL FITNESS – AMSA 558
Marine Safety (Domestic Commercial Vessel) National Law Act 2012
Marine Order 505 (Certificates of competency – national law) 2013
 

Guidance notes on when to use this form
This form is to be used when directed by AMSA. You are not required to complete this form when using the AMSA 426.
Title
Title
Surname
Given names
Date of birth
Nationality
Phone - primary
Phone - other
Email
Street number and name
Town/suburb
State
State
Postcode
Country
B. Medical declaration
  1. Do you have unclear speech or hesitation when you speak?
  2. Do you have trouble hearing a whispered voice or a watch ticking? Hearing aids are acceptable provided that their use does not impede watch keeping duties to be adequately performed.
  3. Do you have a hernia that has not been corrected satisfactorily by a curative operation?
  4. Do you have any artificial limbs? Is any artificial limb likely to prevent you from performing duties on a commercial vessel?
  5. Do you have a cardiac pacemaker implanted?
  6. Have you ever suffered from epileptic seizures?
  7. Do you have insulin dependent diabetes or any form of controlled diabetes
  8. Have you been affected by pulmonary tuberculosis?
  9. Are you suffering from any medical condition or are you aware of a physical or mental capacity that may affect your ability to perform duties under this certificate?

If you answered ‘Yes’ to any of the above, a medical examination and report by a qualified medical practitioner is required.

C. Applicant’s declaration and consent
I declare that
  • to the best of my knowledge and belief I am physically fit and there is no other medical condition or disability likely to prevent me from performing duties effectively as a crew member aboard a commercial vessel.
  • to the best of my knowledge the information provided by me in this application (and any attachments I have included with this application) is true and correct.
  • I consent to the Australian Maritime Safety Authority, as the National Regulator, making all reasonable enquiries in order to verify that the information provided by me in this application (and any attachments I have included with this application) is true and correct.
  • I understand and acknowledge that the Australian Maritime Safety Authority, as the National Regulator, may ask that I provide any information or document that the National Regulator reasonably considers necessary for consideration of this application.
  • I understand and acknowledge that the Australian Maritime Safety Authority, as the National Regulator, may ask another person to provide any information, document or agreement that the National Regulator reasonably considers necessary for consideration of this application.
Signature
Name
Date

Privacy Statement
The collection of information requested in this form is required or authorised by Schedule 1 of the Marine Safety (Domestic Commercial Vessel) National Law Act 2012 (the Act). It will be used for purposes related to the Act and may be provided to Commonwealth or State/Territory government agencies for the purposes of marine safety. Failure to provide the information may result in the transaction not being processed. To contact us, or for more information on how to access or correct your personal information, how to make a privacy complaint, or how your information may be used or disclosed for purposes beyond those described in this statement, visit www.amsa.gov.au/privacy.
How to lodge

For all CoC applications lodge with AMSA 426 form.

For all other applications/purposes please email to AMSAConnect@amsa.gov.au

AMSA form: 558
Version: 1 7/18