Australian Government - Australian Maritime Safety Authority
MEDICAL FITNESS CERTIFICATE FOR A NEAR COASTAL QUALIFICATION – AMSA 559
Marine Safety (Domestic Commercial Vessel) National Law Act 2012
Marine Order 505 (Certificates of competency – national law) 2013
 

Guidance on when to use this form
This form is to be completed by a qualified Medical Practitioner/Optometrist, who should read the the document Guidelines for the medical assessment of near coastal seafarers which can be found at Guidelines medical assessment near coastal seafarers
A. Applicant details
Title (Mr, Mrs, Dr, etc)
Surname
Given names
Street name and number
Town/suburb
State
Postcode
Date of birth
Sex (M / F / X)
Type of certificate of competency (Deck / Dual / Engineering)
B. Proof of identity
Passport Drivers licence Other (specify)
Number

C. General considerations
Domestic seafarers work on vessels in Australian waters, which may extend 200 nautical miles off the coast and thereby be extremely remote from full medical facilities. The primary objectives of a medical assessment of fitness for duty afloat are to ensure that individuals are fit to perform the essential tasks of their job at sea effectively and to anticipate and, where possible, prevent the avoidable occurrence of ill-health offshore which could place individuals, their colleagues and others at risk.
D. Results of examination
  1. Does the applicant have unclear speech or hesitation when they speak?
  2. Is the applicant unable to hear by testing of the whispered voice, watch or other approved tests ? < br /> If ‘Yes’, further testing should be conducted by means of an audiogram.
    • When an audiogram is used, the hearing requirements are:
      • hearing loss in the better ear must be ≤40 decibels (AMA standard) for the frequencies of 500Hz, 1000Hz and 2000Hz; and
      • if hearing level does not meet the standard mentioned in paragraph (a) — a hearing aid may be used if the standard can be met when using the aid.
    • The applicant may meet the standard by demonstrating hearing that meets the standard in 1 ear.
  3. Does the applicant have a hernia that has not been corrected satisfactorily by a curative operation?
  4. Does the applicant have any artificial limbs?
    Will any artificial limb interfere with normal duties the applicant would be expected to perform on a commercial vessel?
  5. Does the applicant have a cardiac pacemaker implanted?
    If ‘Yes’, taking into account the nature of the disease and the reliability of the Pacemaker, is the applicant considered fit to work as a crew member on a commercial vessel?
  6. Does the applicant have a history of epilepsy?
    If ‘Yes’, taking into account the state of the applicant’s health:
    • Is the applicant managing the epilepsy efficiently?
    • Could the applicant perform the normal duties that the applicant would be expected to perform?
    • Will the safe operation of a vessel be affected by the applicant’s condition?
  7. Has the applicant been affected by pulmonary tuberculosis?
    If ‘Yes’, has the disease been controlled or been inactive for at least the previous 6 months?
  8. Does the applicant have insulin dependent diabetes or any form of poorly controlled diabetes?
    If ‘Yes’, is the applicant managing the diabetes effectively?
    If ‘Yes’, please provide a statement as to how the applicant is managing the diabetes
  9. Does the applicant suffer from any medical condition, physical or mental incapacity that may affect their ability to perform duties under this certificate?
    If ‘Yes’, please provide further information below.
E. Medical Practitioner’s declaration

I have evaluated the above named applicant and, on the basis of their personal declaration and my clinical examination, declare that the applicant is fit and is not suffering from a medical condition likely to be aggravated by, or to render him/her unfit for, service at sea or likely to endanger the health of other persons on board.

Note: If the Medical Practitioner is unable to provide an answer in the affirmative to the above declaration, they should not sign this certificate.

Medical Practitioner signature
Medical Practitioner name
Date of examination (valid for 2 years)
Medical Practitioner address
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.
 
F. Duty types
Type of duty Certificate
Deck Master < 24 m NC
Master (Inland waters)
Master < 35 m NC
Mate < 80 m NC
Master < 80 m NC
Engineering Marine Engine Driver Grade 3 NC
Marine Engine Driver Grade 2 NC
Marine Engine Driver Grade 1 NC
Engineer Class 3 NC
Dual General Purpose Hand
Coxswain Grade 2 NC
Coxswain Grade 1 NC
How to lodge
Lodge with AMSA 426 Form
AMSA form: 559
Version: 1 7/18