GOVERNMENT OF BERMUDA

DEPARTMENT OF MARITIME ADMINISTRATION

SEAFARER MEDICAL FITNESS CERTIFICATE
Authorized by the Department of Mari me Administra on,, Government of Bermuda.
Issued under the Provisions of the Interna onal Conven on on Standards of Training, Cer fica on and Watch keeping
for seafarers, 1978 as amended, The Maritme Labour Conven on 2006, and Bermuda
Merchant Shipping (Medical Cer fica on of Seafarers) Regula ons 2013

2.0 Seafarer Informa on

2.1 Family Name 2.1.1 First / Middle Name
NYANDORO CHISHAMISO
2.2 Date of Birth: 11-Jan-83 2.3 Gender: Male: Female : x
2.4 Na onality: ZIMBABWEAN
2.4.1 Passport or seaman’s Book Number: EN375843
Department Rank
MASSAGE THERAPIST
(E.G Deck/Engine/Catering/Other ) /Job:
3.0 Declaraton o f the recognised medical Practi oner (Standards to be met are as per STCW Code Sec on A-I/9)
3.1 Seafarers Documentaton checked at point of examina on Yes x No
3.2 Hearing sa sfactory Yes x
Unaided Hearing sa factory Yes x
3.3 Visual Acuity sa sfactory Yes x
3.5 Sa factory Colour Vision (Deck & Engine Only) Yes
3.5.1 Date of Last Colour Vision Test 29- JUL-22
3.6 Fit for Look-out Du es (Deck & Engine Only) Yes X No
**Visual Aids:(if worn specify which type Spectacles require to carry an addi onal pair of
for what purpose) Contact Lenses spectacles
3.7 Medical Fitness Category
1. FIT x No Restrictons or Li mitatons, Full Duraton Yes X No
2. FIT Subject To Restric ns and/or Limited Duraton, See Below
++Restricted Dutes:: NONE
++Restricted to Ship Type/Geographical area/Other: NONE
The Above MUST NOT contain any clinical informa on
3.8 The Seafarer is free from any medical condi on likely to be aggravated by sea service or to endanger the
Health of other persons on board Yes x No
3.9 Examina on Date : 13-JUN-25 3.10 Cer ficate Expiry Date: 12-JUN- 2027
I confirm that the above name seafarer was examined by me and found to be fit for sea service as stated in
Sec on 3.7 and 3.8 above
(Please Keep Signature Within This Box) DR Robert David Dungan

4.0 Signature of duly authorized Medical Prac oner Full Name (Print) of duly Authorized Medical Prac oner
4.1 Medical Prac oner’s Official Stamp Medical Prac oner’s Contact Informamon
Address: 25 GLENWOOD DRIVE DURBAN

CR R.D DUNGAN MBBCH DOH 0308706 Phone: 031 2618291

E-mail: docdavid@shipmed.co.za

5.0 Seafarer Declara on – I have been informed by the medical prac on er of the content of the medical cer ficate and of the
right to review in accordance with paragraph 6 sec on A -1/9 of the STCW Code in the rela on to medical fitness standards
or any limita ons or restric ons imposed on ability to work. (see overleaf for review procedure)
Seafarers’ Signature (Please Keep Signature Within This Box) Serial Number:D28318110133
*All Cer ficates are Valid for a maximum of Two (2) Years from the examina on d ate or One (1) Year if the seafarer is
under 18 years of age Colour vision tests are valid for Six (6) years
THE ORIGINAL CERTIFICATE SHOULD BE ISSUED TO THE SEAFARER
BSME CERT FORM -5a
Bermuda Seafarers’ Medical Fitness Certficate Rev. 07.16
 PHYSICAL EXAMINATION REPORT/ CERTIFICATE
OFFICE OF THE MARITIME ADMINISTRATOR
CONFIDENTIAL DOCUMENT
REPUBLIC OF THE MARSHAL ISLANDS
SURNAME GIVEN NAME(S)

DATE OF BIRTH PLACE OF BIRTH SEX

MONTH DAY YEAR CITY COUNTRY MALE FEMALE

EXAMINATION FOR DUTY AS: MAILING ADDRESS OF APPLICANT:
MASTER
DECK OFFICER
ENGINEERING OFFICER
RADIO OFFICER
RATING
MEDICAL EXAMINATON (SEE REVERSE SIDE FOR MEDICAL REQUIREMENTS) STATE DETAILS ON REVERSE SIDE)
HEIGHT WEIGHT BLOOD PRESSURE PULSE RESPIRATION GENERAL APPEARANCE

VISION : RIGHT EYE LEFT EYE HEARING:

WITHOUT GLASSES ___________ / __________
WITH GLASSES ___________ / __________ RT. EAR ___________ LEFT EAR ______________

COLOR TEST TYPE: BOOK LANTERN IS COLOR TEST NORMAL? YES NO (IF “No EXPLAIN ON PAGE 2)
ARE GLASSES OR CONTACT LENSES NECESSARY TO MEET THE REQUIRED VISION STANDARD? YES NO

HEAD AND NECK HEART (CARDIOVASCULAR)

LUNGS SPEECH( DECK/NAVIGATIONAL OFFICER AND RADIO OFFICER)

IS SPEECH UNIMPAIRED FOR NORMAL VOICE COMMUNICATION?
EXTREMITES:
UPPER _______________________ LOWER________________________________
Is APPLIANT VACCINATED IN ACCORDANCE WITH WHO RECOMMENDATIONS? YES NO
IS APPLICANT SUFFERING FROM ANY DISEASE LIKELY TO BE AGGRAVATED BY WORKING ABORD A VESSEL, OR TO RENDER HIN/ HER UNFIT
FOR SERVICE AT SEA OR LIKELY TO ENDANGER THE HEALTH OF OTHER PERSONS ON BOARD? Y ES No
IF YES, PLEASE ENTR EXPLANATION IN THE SECTION AT THE BOTTOM OF ON PAGE 2
IS APPLICANT TAKING ANY NON -PRECRIPTION OR PRESCRIPTION MEDICATIONS? YES NO

________________________________ ___________________________ ___________________________________

SIGNATURE OF APPLICANT DATE OF EXAMIATION EXPIRY DATE
THIS IGNATURE SHOULD BE AFFIXED IN THE PRESENCE OFB THE EXAMINING PHYSICIAN.

THIS IS TO CERTIFY THAT A PHYSICAL EXAMINATION WAS GIVEN TO:_________________________________

THIS APPLICANT IS CERTIFIED FREE OF COMMUNICBLE DISEASE (OR VIRUSES FOR COOKS): YES NO
SEAFARER IS FOUND TO BE FIT/ NOT FIT FOR DUTY AS A MASTER/ DECK OFFICER/ ENGINEERING OFFICER/
R RADIO OFFICER/ RATING/ CHIEF COOK/ COOK WITHOUT ANY RESTRICTIONS/ WITH THE FOLLOWING
RESTRICTION:
NAME AND DEGREE OF PHYSICIAN ____________________________________________________________
ADDRESS_____________________________________________________________________________________
NAME OF PHYSICIAN’S CERTIFICATING AUTHORITY____________________________________________
DATE OF ISSUE OF PHYSICIAN’S CERTIFICATE__________________________________________________
SIGNATURE OF PHYSICIAN ________________________________________ ________________________

This certificate is issued by authority of the Maritime Administrator and in compliance with requirements
Of the medical examination seafarers) convention 1946 (ILO No. 73)

Rev. 9/14 MI-105M

 MEDICAL REQUIREMENTS
All applicants for an officer certificate, Seafarer’s identification and record book or certification of special qualificatio ns shall be required to have a physical examination
reported on this Medical Form completed by a certificated physician. The completed medical form must accompany the application for officer’s certificate application for
Seafarer’s identification and record book, or application for certification of special qualification. This physical examination must be carried out within the 24 months
immediately preceding application for an officer certificate, certification of special qualification or Seafarer’s identifica tion and record book. The examination shall be
conducted in accordance with RMI MG -7-47-1. Such proof of examination must establish that the applicant is in satisfactory physical and mental condition for the
specific duty assignment undertaken and is generally in possession of all body faculties necessary in fulfilling the requirements of the seafaring profession.
In conducting the examination, the certified physician should, where appropriate, examine the seafarer’s previous medical records (including vaccinations) and
information’s on occupational history, noting any diseases, including alcohol or drug-related problems and/or injuries. In addition, the following minimum requirements
shall apply:

(a) Hearing
. All applicants must have hearing unimpaired for normal sounds and be capable of hearing a whispered voice in better ear at 15 feet (4,57m) and in poorer ear
at 5 feet (1.52m)
(b) Eyesight
. Deck officer applicants must have (either with or without glasses) at least 20/20 (1.00) vision in one eye and at least 20/40 (0.50) in the other. If the applicant
wears glasses, he must have vision without glasses of at least 20/160 (0.13) in both eyes. Deck officer applicants must also have normal colour perception and
be capable of distinguishing the colours red, green, blue and yellow.
(c) Dental
. Seafarers must be free from infections of the mouth cavity or gums.
(d) Blood Pressure
.An applicant’s blood pressure must fall within an average range, taking age into consideration.
(e) Voice
. Deck/Navigational officer applicants and Radio officer applicants must have speech which is unimpaired for normal voice communication.
(f) Vaccinations
.All applicants should be vaccinated according to the recommendations provided in the WHO publication, International Travel and Health, Vaccination
Requirements and health Advice, and should be given advice by the certified physician on immunizations. If new vaccinations are given, these should be
recorded.
(g) Disease or Conditions
.Applicants afflicted with any of the following disease or conditions shall be disqualified: epilepsy, insanity, senility, al coholism, tuberculosis, acute venereal
disease or neurosyphilis, AIDS, and /or the use of narcotics.
(h) Physical Requirements
.Applicants for able seafarer, bosun, GP-1, ordinary seafarer and junior ordinary seafarer must meet the physical requirements for a deck /navigational officer’s
certificate.
.Applicants for fire/water tender, oiler/motor, pump technician, electrician, wiper, tanker rating and survival craft/ rescue boat crewmember must meet the
physical requirements for an engineer officer’s certificate.

IMPORTANT NOTE:
A copy of the MI-105M must accompany the application. The Applicant must retain the original of the MI-105M s evidence of physical qualification while serving on
board a vessel
An applicant who has been refused a medical certificate or has had a limitation imposed on his /her ability to work, shall be given the opportunity to have an additional
examination by another medical practitioner or medical referee who is independent of the ship owner or of any organization of ship owner or seafarers.
Medical examination reports shall be marked as and remain confidential with the applicant having the right of copy to his/her report. The medical examination report shall
be used only for determining the fitness of the seafarer for work and enhancing health care.

DETALS OF MEDICAL EXAMINATION

(To be completed by examining physician; alternatively, the examining physician may attach a form similar or identical to the model provided in appendix 1 of RMI MG-
7-47-1.)

Rev. 9/14 MI-105M