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
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
Guidance on when to use this form
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
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.
If ‘Yes’, please provide a statement as to how the applicant is managing the diabetes
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.
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,
|Type of duty
Master < 24 m NC
Master (Inland waters)
Master < 35 m NC
Mate < 80 m NC
Master < 80 m NC
Marine Engine Driver Grade 3 NC
Marine Engine Driver Grade 2 NC
Marine Engine Driver Grade 1 NC
Engineer Class 3 NC
General Purpose Hand
Coxswain Grade 2 NC
Coxswain Grade 1 NC