MANUAL MEDICAL EXAMINATIONS NSI. January Rev.1

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1 MANUAL MEDICAL EXAMINATIONS NSI January 2017

2 Contents 1 Introduction 2 2 Medical examinations of seafarers Areas of concern Duty categories Vision standards Hearing standards Fitness criteria Filling out the Seafarer Medical Certificate 9 3 Medical examiners appointment and recognition 10 4 Additional information Registering results Surveillance Ordering certificates 11 5 Rules and regulations Merchant Shipping Medical Examination Regulations ILO/IMO guidelines; appendix A through E 22 1

3 1 Introduction Medical examinations for Dutch Flag personnel may only be performed by doctors who have been appointed or recognized by The Netherlands Administration. Applicable rules and procedures are embedded in Dutch Law. This NSI (Netherlands Shipping Inspectorate) manual is to be used by all appointed and recognized doctors abroad and replaces all previous issues. The examining doctor should assess whether the candidate meets applicable medical standards and whether he or she is capable to perform their duty on board ship. Next to the seafarer s own fitness for duty, secondary safety of fellow crew members and other mariners should be taken into consideration. In order to judge any safety risks, the examining doctor should be well aware of the working conditions on board ship. This manual addresses seafarers examinations, procedures of appointment and recognition of examining doctors and practical matters such as ordering certificates and registration of issued SMC s or Declarations of Medical Unfitness. Finally the medical standards are attached. Any additional instructions issued by the NSI s Medical Adviser should be executed, as they are to be considered mandatory as written in article 3, first note, of the Merchant Shipping Medical Examination Regulations Issuing SMC s to the obese (page 8) and will be addressed more specifically. NSI will focus on surveillance and enforcement concerning this topic more strongly in In case of any uncertainties or the need of clarification, please consult the NSI Medical Adviser via mas@ilent.nl. 2

4 2 Medical examinations of seafarers 2.1 Areas of concern Medical examination requirements The official text of the examination procedure, the examination directions and the medical requirements can be found in the Ministerial Decree "Medical Examinations of seafarers 2012". The medical standards within this Decree are a copy of annex A through E of the ILO/IMO Guidelines on the medical examination of seafarers. Annex A and B include the hearing and vision standards. Annex C covers the physical capability requirements and annex D the fitness criteria for medication use. Annex E describes the fitness criteria for common medical conditions. Duty categories Since August 20 th 2013 four groups are discerned: Seafarers with look-out or watch duties on the bridge. Seafarers with look-out or watch duties in the engine room. Seafarers without look-out or watch duties, but with safety or security duties. Seafarers without any duties mentioned above. All crew members who execute look-out or watch duties on deck and bridge or in the engine room must comply with the hearing and vision standards of annex A and B of the ILO/IMO-guidelines, which are derived from the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (STCW). The hearing and vision standards of the seafarers who do not need to comply with STCW, group four without safety duties, are mentioned in annex 2 of the Ministerial Decree "Medical Examinations of seafarers 2012". All four groups have to comply with the Maritime Labour Convention (MLC). This means that the first three categories have to comply with both the STCW and the MLC standards, group four solely with the MLC standards. Verification prior to medical examinations Prior to medical examination the identity of the candidate should always be verified and previously issued SMC and/or exemption/dispensation or rejection should be presented by the examinee. Contents medical examination Case history and family history A general physical examination A general assessment of the mental state Test for tuberculosis if indicated Urine tests Additional tests of the blood or feces if indicated Examination of the visual system Examination of the auditory system On indication, request additional examinations by a specialist. Anamnesis, physical examination and assessment of the seafarers mental state may solely be performed by the appointed or recognized doctor and is therefore not to be passed on to nonappointed staff. This also counts for the issuing and signing of medical certificates. Emergency situations etc. During the examination of seafarers with look-out or watch duties one should not only assess fitness for duty under standard conditions, but consider demanding situations at sea, such as emergencies, climate changes and severe weather conditions. Also consider they will have attend STCW-trainings. Failing a required STCW-training will restrict the seafarer s duties. Example: Testing for tuberculosis A chest X-ray, IGRA-test or Mantoux-test is part of the examination, if the seafarer originates from, or is employed in a tuberculosis risk area, and/or is so indicated for medical reasons. At the time of the examination, the test for tuberculosis may be not older than 1 month (see 2.5 on page 8). 3

5 Visual acuity in youth It is of importance to note that visual acuity in youth may still develop until the age of 25. An 18 year old youth who hardly meets standards may well fail by the time he/she is 25 years old. The examining doctor should point out this risk to such examinees. Students It is not mandatory for freshmen to have had an examination before starting their education. Not until the student s first journey out to sea a SMC is mandatory. In order to prevent harsh situations in which an unprepared student is declared unfit for duty halfway his/her education, NSI advises colleges and doctors to promote voluntary examinations before starting at maritime college. Fit for duty Only examinees that meet appropriate standards may be declared fit for duty. The appointed doctor may order restrictions on the SMC. When in doubt, the medical adviser may be consulted. Unruly declaration of fitness may result in serious problems for examinee, emloyers, insurance companies and the examining doctor. Period of validity Two years, unless a restriction in time is indicated. Youth under 18 are always restricted to a period of one year or less. Unfitness Any examinee not meeting standards and not holding a valid exemption, must be decalerd unfit for duty. The examinee is handed a Declaration Of Medical Unfitness and is explained his/her right to an examination by a referee. Re-examination by referee Any examinee (outside The Netherlands) who wishes to apply for a re-examination by referee, may be directed to NSI s medical adviser for further instructions. Exemptions NSI s medical adviser may issue exemptions for individual cases. Questions on the issuing or renewal of such exemptions may be addressed at mas@ilent.nl Non-Dutch crew on non-dutch Flag ships Several countries have recognized The Netherlands Seafarer Medical Certificate to be valid for their own flag. NSI does not object to issuing Dutch certificates for foreign flag crew if requested so. 4

6 2.2 Duty categories DUTIES ON BOARD Master / captain Pilot Mate, officer MO / Maritime officer Officer in charge of a navigational watch Skipper (fishery) Mate-engineer (fishery) Rating deck Bosun Able body (A/B) Sailor Deckhand Rating deck-engineroom Ship's technician Trainee maritime officer Student Engineer Officer in charge of an engineering watch Rating engine room Motorman Cook / Assistant cook Physician / Doctor Radio officer Rating Ordinary sailor (O/S) General purpose (G/P) = GPA Electrician Fitter / Wiper / Greaser / Welder Hotel manager Steward / Purser Safety officer Medic Stewardess / Receptionist Cook / Assistant cook Physician / Doctor Radio officer Rating Ordinary sailor (O/S) General purpose (G/P) = GPA Electrician Etc. REGISTRATION AS Look-out or watch duties on the bridge Watch duties in the engine room Rating without look-out or watch duties, but with safety and / or security duties Rating without above mentioned duties 5

7 2.3 Vision standards Vision Demands under STCW are written in table A-I/9 of this convention. This table is part of appendix A of the ILO/IMO guidelines on the medical examination of seaferers (annex 5.2). Category Lookout or watchkeeping on the bridge Lookout or watchkeeping in the engine room No lookout or watchkeeping, but with safety- or security tasks Seafarers without any of the above duties Minimal demands Each individual eye, either with glasses or lenses 0.5, uncorrected 0.1 Each individual eye, either with glasses or lenses 0.4, uncorrected 0.1 Each individual eye uncorrected 0.1 Both eyes simultaneously, either with glasses or lenses 0.1 Colour vision Demands under STCW are written in table A-I/9 of this convention. This table is part of appendix A of the ILO/IMO guidelines on the medical examination of seaferers (annex 5.2). Seafarerers with lookout or watchduties on the bridge must comply with CIE colour vision standard 1 or 2, while seafarerers with lookout or watch duties in the engine room must comply with CIE colour vision standard 1, 2 or 3. CIE is the Commission Internationale de l Eclairage. This internationally acclaimed committee has set standards on colour vision for seafarers in 2001, which have been adopted by STCW (Standards of Training, Certification & Watchkeeping). Seafarerers with lookout or watch duties on the bridge The initial test for colour vision is Ishihara s test. A score of 0, 1 or 2 mistakes complies with standard 1. If in doubt, the standard advises an equivalent test, such as Hardy, Rand and Rittler (HRR). Mild defect = pass, medium or strong defect = fail. Three or more mistakes in Ishihara s, but 0 mistakes in the Lantern test, complies with standard 1 also. 1 or 2 mistakes in Lantern test complies with standard 2. 0, 1 or 2 mistakes in Ishihara = pass 3 mistakes or more in Ishihara -> HRR test: mild = pass, medium or strong = fail Lantern test: 0, 1 or 2 mistakes = pass, 3 or more mistakes = fail Seafarerers with lookout or watch duties in the engine room Compliance with standards 1 or 2 = pass. If failed for either of these, but tested for no more than one crossing in Farnsworth s D15 test = pass. Seafarers without lookout or watch duties, but with safety or security tasks (category 3) or all other personnel (category 4) No colour vision requirements. Colour vision must be tested every six years. 6

8 2.4 Hearing standards Demands under STCW are written in appendix B of the ILO/IMO Guidelines on the medical examination of seaferers. STCW (categories 1, 2 and 3, with security tasks) Hearing capacity for seafarers apart from those identified below should be an average of at least 30 db (unaided) in the better ear and an average of 40 db (unaided) in the less good ear within the frequencies 500, 1,000, 2,000 and 3,000 Hz (approximately equivalent to speech-hearing distances of 3 metres and 2 metres, respectively). It is recommended that hearing examinations should be made by a pure tone audiometer Category 4 (no security tasks) 1. A test with the tone audiometer is performed once every 2 years. A hearing loss of an average of 40 db (HL) for the best performing ear is a reason for unfitness. A hearing loss of an average of 40 db (HL) or more for the worst ear is a reason for unfitness. The applicable norm is the arithmetic mean of the unmasked conducting thresholds at 500, 1000, 2000 and 3000 Hz. If the equipment does not allow for measurement at 3000 Hz, the threshold at 3000 Hz per ear may be calculated on the basis of the average of thresholds at 2000 and 4000 Hz for the same ear. 2. Should the mean hearing loss exceed 40 db (HL) while speech can clearly be understood at 2 metres distance with each ear separately and without the use of a hearing-aid, hearing is considered to be sufficient. 7

9 2.5 Fitness criteria The "Merchant Shipping Medical Examination Regulations 2012" are based on the ILO/IMO Guidelines on the medical examination of seafarers. The physical requirements are set out in Appendix E of this directive, see Annex 5.2. Based on this new directive, the Norwegian Centre for Maritime Medicine (NCMM) have, in collaboration with the International Maritime Health Association (IMHA), written a handbook on performing medical examinations for seafarers: handbook.ncmm.no/ Some common ailments where using this handbook may be of aid: The use of anti-coagulantia Refer to chapter 7, in particular the HAS-BLED Bleeding Risk Score: Diabetes The decision tree chapter 12: Obesity The decision tree chapter 13: Obesity increasingly leads to dangerous situations, such as seafarers unable to fit into their rescue suits, casualties too heavy to be taken into safety, or those short of breath after minor exercise. For NSI to monitor this better, please note: BMI > 35: a maximum period of fitness of 12 months. BMI > 40: any declaration of fitness only after NSI consultation mas@ilent.nl Hypertension The decision tree chapter 16: Tuberculosis Seafarers sometimes travel to areas where the risk of tuberculosis is considered much higher than it is in The Netherlands. Also, crew often live and work close to each other and frequently team up with crew who are possibly from higher prevalence TB areas. Seafarers from TB risk areas should always be screened for tuberculosis. Other seafarers should be screened if their anamnesis or physical examination indicates to do so. Risk areas are considered to be any areas where the risk of infection is greater than the risk for the Dutch population in general, and if the incidence of tuberculosis is higher than 50 cases per 100,000 inhabitants and determined as such by the WHO. TB testing may be done by chest X-ray, Mantoux test or blood test (IGRAtest). Tuberculosis risk areas Refer to: 8

10 2.6 Filling out the Seafarer Medical Certificate Seafarer information Four categories of seafarers are determined. The first three categories must comply with both STCW-standards and the Maritime Labour Convention (MLC). The fourth category concerns seafarers without look-out, watch, safety and security duties. This category does not need to comply with STCW. They need only comply with MLC regulations. Limitations on validity When the examinee meets the standards determined in the final column of appendix E of the ILO/IMO Guidelines on the medical examination of seafarers, and there is no medical indication for a limited period of validity, Until 2 years after the date of issue and Worldwide may be ticked. Limiting conditions may concern: a) Limitation in time: tick third box Period of validity (Limited period otherwise), followed by the period in months. Fill out date of expiry appropriately. b) Area of validity: tick second box Limited area and note restriction in miles off coast and/or specific area. I.E.: Within 30 miles of the Dutch coast or Limited to The North Sea. c) Limitation on duties: under Limitations on fitness, note as required. I.E.: No solo watch keeping. d) Medical aids: under Limitations on fitness, note as required. I.E.: Hearing aids are to be used in both ears. Judgement medical fitness seafarer under STCW-Convention For the first three categories tick either yes or no. In case of a category four examination, tick the Not applicable box. Appendix A of the ILO/IMO Guidelines on the medical examination of seafarers contains the STCW-code s vision requirements. Appendix B contains the STCW-code s hearing requirements. Testing of colour vision is only required for those with look-out or watch duties. (Either bridge or engine room, category 1 and 2). Colour vision should be tested every six years. The date of testing must be copied to the next certificate, unless the six years period expires during the date of validity of the new certificate, in which case the colour vision test should be repeated. Signature Both seafarer and examining doctor should sign the SMC. Without both signatures the certificate will be invalid. Official stamp and name of the issuing authority This is your name and stamp as recognized by The Netherlands Shipping Inspectorate. Issue date and expiry date Should additional examinations be required, the date of issue may be a later date than the original date of examination. The expiry date is usually the date of issue + 24 months, unless a limited period of validity is indicated. 9

11 3 Medical examiners appointment and recognition Medical examinations of shipping personnel for Dutch flag may only be carried out by physicians appointed or recognised by the Minister of Infrastructure and the Environment. Appointed doctors are qualified to issue SMC s for all seafarers. Recognized doctors are qualified to issue SMC s solely for seafarers without any look-out or watch duties, nor any safety or security duties. The appointment is regulated in the Seafarers Act, Seafarers Merchant Shipping and Sailing Order and the Manning Order Deep-Sea Fishing respectively. Any request is assessed on the Minister's behalf by the Medical Adviser of the Netherlands Shipping Inspectorate. During this assessment, due consideration is given to the regional requirement and the number of medical examinations for shipping personnel that a physician expects to perform. During the assessment of the application it is ascertained whether the physician is employed in a relevant area in which general physical examination and the examination of the vision and hearing form part of the day-to-day practice and whether the physician has experience in recognising diseases and conditions. The physician signs a declaration stating that he agrees with the aforementioned aspects and a number of other conditions for appointment. It is important that he/she agrees to familiarize him or herself with the various maritime professions, so that he/she is sufficiently familiar with the living and working conditions onboard ships when performing the examinations. The examination facilities should satisfy the quality requirements and the physician should be sufficiently available and reachable. The medical examiner must have access to the internet and an address. The conditions stated in this declaration have been taken from the relevant legal acts. As a result of this declaration there is no misunderstanding about the fact that the medical examiner is aware of his formal rights and duties. The foreign physician signs the same declaration as Dutch physicians and in addition to this a certificate of non-suspension. For a general assessment of the professional competence of the physician, a visit can be part of the appointment procedure, in addition to a test comparable to that taken by Dutch physicians concerning professional expertise, practical experience and professional equipment. During this visit, not only is the individual physician assessed, but attention is also paid to the following aspects of the clinic or examination establishment: a valid quality system, recognition by the national government, cooperation with subspecialists, the protection of privacy and the prevention of fraud. The authority to perform medical examinations on ships personnel is limited to a specific location for medical examinations and is strictly personal. Even if some of the examinations are carried out by third parties, the medical examiner remains responsible. Medical declarations are valid only if they have been stamped with a name stamp recognized by the Netherlands Shipping Inspectorate that is accompanied by a signature which is also known to the NSI. An updated list of all appointed and recognized doctors will be published on The appointment or recognition extends to a maximum of 5 years after the date on which it is issued and will not be automatically renewed. After this period, any medical declaration issued will not be valid. The medical examiner can only continue to perform medical examinations if he/she has requested a new appointment or recognition in good time and was granted this. 10

12 4 Additional information 4.1 Registering results Registering issued medical certificates. Each working day results must be reported via The subject line of your should contain the doctor s name. The message should contain the seafarer s full names and d.o.b. Per working day only one concluding should be sent. Registering declarations of unfitness These must be reported via mas@ilent.nl, please add the declaration in pdf format. For any questions or ordering of certificates, please use mas@ilent.nl 4.2 Surveillance Periodical surveillance Periodical audits of seafarers examinig doctors is part of NSI s inspection routines. A typical audit will comprise of: Conversations with appointed or recognized doctors and staff; Discussing cases; Reviewing facilities and equipment; Reviewing medical files and means of archiving; Provide answers to possible questions and unclarities. Findings The auditee shall receive a review copy of the inspector s report as soon as possible. A final report shall be written and filed thereafter. Any NSI instructions should be executed without delay. 4.3 Ordering certificates Please order your by mas@ilent.nl You are requested to place a single order to cover an examination period of approximately 6 months. Please allow a lead time of 14 days. The forms: Declaration of medical unfitness and Medical examination form can be downloaded from our website. 11

13 5 Rules and regulations 5.1 Merchant Shipping Medical Examination Regulations 2012 Ministerial Decree with respect to establishing the rules concerning the medical suitability and medical examination of seafarers. Article 1. Definitions In this regulation the following terms shall have the following meanings: a. act: Seafarers Act [Wet zeevarenden] b. medical examination: medical examination as referred to in article 105, subsection 1, of the Seafarers Merchant Order Merchant Shipping and Sailing or article 61, subsection 1, of the Manning Order Fishery. c. candidate: natural person who undergoes a medical examination d. risk area: area outside of the Netherlands, where the risk of infection with tuberculosis is greater than the infection risk for the Dutch population, as apparent from an annual prevalence of tuberculosis in the country concerned which is higher than 50 cases per 100,000 inhabitants and as determined by the World Health Organization. Article 1a 1.The physician who is appointed by the minister complies with the conditions stated in Annex 4. 2.The physician who is recognized by the minister complies with the conditions stated in Annex 5. Article 2. Items to be submitted and checked during the medical examination 1. Prior to the medical examination, the examining physician checks: a. the candidate s seaman s book, or b. if the candidate is not yet in the possession of a seaman s book, the declaration by or on behalf of the shipping company that the candidate is in service or will enter into service, accompanied by valid identification, or c. proof that the candidate has registered for a recognized nautical course, accompanied by valid identification. 2. Furthermore, the examining physician checks: a. the status of the seafarer s examination, in order to check whether or not the examinee has been declared unfit previously by another examining doctor; b. if applicable, the result of a test for tuberculosis (chest X-ray, IGRA or Mantoux test); c. if applicable, a valid dispensation, issued by the Medical Adviser of the Netherlands Shipping Inspectorate as referred to in Chapter 6 of the Seafarers Merchant Shipping and Sailing Order and Chapter 7 of the Manning Order deep-sea fishing. Article 3. Examination and medical survey 1. The medical examination takes place with due regard to the examination directions and in accordance with the medical standards, stated in Annex 1, Annex 2, or Appendix A through E of Guidelines on the medical examinations of seafarers/ International Labour Office, Sectoral Activities Programme, International Migration Organization 2013 (ILO/IMO/JMS/2011/12) respectively. 2. During the medical examination the examining physician will make use of the Examination Form. The examining physician will retain the Examination Form and any other documents related to the examination, for the duration and in the manner determined by or pursuant to the Dutch Medical Treatment Contracts Act. 3. The medical examination of the general physical suitability comprises an examination into previously experienced diseases and accidents (anamnesis), inherited and chronic diseases which occur in the family (family anamnesis), a general assessment of the candidate's mental state of health, chemical urine tests, as well as a general examination of the body, eyes and ears in order to determine whether the candidate satisfies the standards, as referred to in subsection 1 of this article. Article 4. Specialist report or partial examination 1. The examining physician requests information from the attending physician if, according to Article 3.1, a specialist report is required or if there are doubts as to whether the standards have been met. If there is insufficient information, the examining physician refers the candidate to a specialist for an additional examination. 2. Once the information from the attending physician or the report from the additional examination by a specialist has been received, the examining physician can complete the examination. 12

14 Article 5. Issuing the declaration of fitness 1. The examining physician who has performed a medical examination for which the result is favourable, will present the candidate with a Seafarers Medical Certificate. The certificate will state the duty category, period of validity and area of validity. 2. The examining physician will authenticate the certificate with his signature and name stamp. Article 6. Declaration of medical unfitness (DOMU) 1. If the Seafarers Medical Certificate is to be withheld, the examining physician will inform the candidate of this and state the reason or reasons for the rejection. 2. Candidates can only be rejected if the entire medical examination has been carried out in accordance with articles 3 and The examining physician also informs the candidate of his right to a re-examination. 4. For each rejection for maritime service, the examining physician immediately informs the Medical Adviser of the Netherlands Shipping Inspectorate using the DOMU, and stating the reason or reasons for the rejection. 5. The examining physician presents the candidate with a copy of the DOMU and on this states the reason or reasons for the rejection. 6. If during an interim examination on the basis of article 23 of the act the examining physician notices that the candidate is temporarily or permanently unfit for maritime service, he will proceed as prescribed in subsections 1 to 5 of this article. 7. The candidate who wants a re-examination will approach a referee and submit his copy of the DOMU. Article 7. Re-examination 1. After a declaration of temporary unfitness has been issued, a re-examination can only be performed by the examining physician who rejected the candidate in the first place, unless the candidate wishes to make use of his right to re-examination by an appointed referee. 2. After a declaration of permanent unfitness has been issued, a re-examination can only be performed by an appointed referee. Article 8. Procedure to be followed by arbitrator during a re-examination 1. For the re-examination, articles 3 and 4 are equally applicable, with the understanding that the elements for which the candidate has already been declared fit by the examining physician during the medical examination do not need to be repeated, unless there are doubts about the result. 2. In some cases the re-examination can solely consist of assessing the medical data available. 3. In the case of a declaration of fitness, article 5 is equally applicable. 4. In the case of rejection, subsections 1 and 5 of article 6 are equally applicable. 5. For the issuing of a dispensation, the referee sends a recommendation to the Medical Adviser of the Netherlands Shipping Inspectorate. Article 9. [cancelled] Article 10. Recording the results of the medical examination The results of the medical examinations are recorded by the examining physician in the designated register, with due consideration to the instructions from the Medical Adviser of the Netherlands Shipping Inspectorate, and are kept for the period decreed by the Adviser. Article 11. Forms 1. The model of the Seafarers Medical Certificate is the model as included in Annex For the Seafarers Medical Certificate, the Declaration of medical unfitness and the Examination form, the examining physician will solely use the forms that are provided to him by the Medical Adviser of the Netherlands Shipping Inspectorate. Article 12. This decree is based on Articles 104, 106, first, second and third member, and 110, seventh member, of the Manning Order Merchant Shipping and Sailing and the Articles 60, third member, and 62, first, second and third member, of the Manning Order Deep-Sea Fishing. Article 13. This decree shall be quoted as: Merchant Shipping Medical Examination Regulations

15 Annex 1 Examination directions The maintenance and promotion of the safety at sea entail inter alia conscientious medical examinations of those seafarers to whom Dutch legislation applies. In general, the person involved should be free from any abnormality, disease or injury which obstructs a safe performance of the duties in order to qualify for a medical certificate. In this respect it is of particular importance to promptly recognize and treat (or have treated) those disorders which clearly increase the risk to the safety on board. A seafarer with safely and/or security duties should at all times be able to act adequately in case of an emergency. He must not only be able to bring himself in a safe position, he must also be able to assist in extinguishing a fire, the launching of life-saving devices and the assistance of crew members and passengers. Furthermore, his (her) presence may cause no danger to the health of the other persons on board. Assessment of an experienced seafarer To those who have performed a maritime job for a length of time, it is reasonable to be flexible in a number of cases. The issue of a Seafarer medical certificate, incidentally and in an individual case, when there are grounds for unfitness, requires that agreement has been reached upon this beforehand with the Medical Adviser of the Netherlands Shipping Inspectorate. Consultating the medical adviser If the assessment of fitness or the degree of unfitness gives rise to doubts, consultations should be held with the Medical Adviser of the Netherlands Shipping Inspectorate. Specific working conditions on board In conducting the examination, the examining doctor should give consideration to the specific working conditions on board, which depending on the vessel type and sailing area may vary greatly though: a. the pattern of work on board exhibits physical and mental peaks at irregular intervals; b. the work on board is not infrequently performed in bad weather conditions or powerful winds and in alternating cold and hot circumstances; c. depending on the vessel type one has to work in more or less restless surroundings with much background noise and movement; d. work on board is accompanied by considerable physical stress, in addition to which plenty of going upstairs and downstairs, maneuvering among obstacles and limited room for movement with sometimes an unfavorable position during work, bring along additional stress to the musculoskeletal system; e. the nature of duties is such that there is not always an opportunity to eat and sleep at regular times, and f. the number of crew members on board has reduced considerably compared to the past. If a person on board is out of circulation through ill-health, his job has to be taken over by colleagues. Vigilance and concentration Regarding the medical examination of seafarers with safety and/or security duties it is also important to realize that many activities on board call for constant alertness: a. navigating, whereby particular alertness is called for when sailing at night, in fog or in bad weather conditions; b. watch keeping in the engine room, particularly in so-called "stand-by" situations, which call for constant alertness in order to be able to maneuver at any given moment; c. working with and being responsible for the transport of dangerous goods; d. working on and in the vicinity of machinery with moving parts, such as cranes, winches and windlasses etc.; e. the performance of work on electrical wiring and steam conduits, and f. the performance of work a great heights both inside and outside deep holds. 14

16 Limited medical care on board It should be borne in mind that if careless examination for example results in an ulcer or inguinal hernia being overlooked, the life of the seafarer may be endangered if he suffers a severe stomach hemorrhage or if his inguinal hernia becomes strangulated. Adequate medical assistance is very remote at such a moment. It is therefore important to recognize during the examination the disorders for which treatment is to be expected. Thus one, for example, has to reckon with the limited -and often late- opportunities for dental assistance. Risk of infection Seafarers are living close together for quite a long time. Infectious diseases are therefore a serious problem and may endanger the safety of the vessel. Especially during the examination of personnel which is involved in preparing food and catering extra attention has to be paid to it. Safety Wearing personal protective means must be possible without any problem and must not be obstructed by physical disorders or restrictions. One should think in this case of safety helmets and safety goggles, masks, ear protection, safety shoes and physical condition. Wearing a compressed-air apparatus of 15 kg for minimally 20 minutes requires a good physical condition. Special protective clothing is worn then. While extinguishing a fire one has to work under great pressure in a warm atmosphere where maneuvers through narrow holes and corridors are possible. Examination directions, directives for rejection, medical standards In addition to the examination directions in this Annex 1 and the directives for rejection given below, the medical standards in Annex 2 and appendix A - E from the Guidelines on the medical examinations of seafarers/ International Labour Office, Sectoral Activities Programme, International Migration Organization 2013 (ILO/IMO/JMS/2011/12) should be applied during the examination of seafarers. Directives for rejection Medically unfit for service at sea is the person who suffers from a disease, abnormality or injury: a. which can obstruct a safe performance of duties; b. because of which the seafarer is not at all times able to act adequately in case of an emergency; c. which may deteriorate during his stay on board, in such a way that this causes an unacceptable risk to the health or safety of himself or other crewmembers, or a serious nuisance to other persons on board; d. which needs a treatment, which requires prolonged medical supervision or which can necessitate immediate medical intervention, or e. which can endanger the health of other crewmembers. Annex 2 Instructions regarding seafarers without look-out duties and without safety or security duties. (Only non-stcw, category 4 personnel). Eyes and vision 1. Visual acuteness is assessed with the help of the Chart of Landolt TNO, the Snellen character chart or another test which may be considered to be equivalent. With both eyes simultaneously, if necessary with own (spare) glasses or contact lenses, a vision of 0.1 should be reached. 2. If optic correction devices have been used at the examination, adequate spare glasses must be shown to the medical examiner. Ears and hearing 1. A test with the tone audiometer is performed once every 2 years. A hearing loss of an average of 40 db (HL) for the best performing ear is a reason for unfitness. A hearing loss of an average of 40 db (HL) or more for the worst ear is a reason for unfitness. The applicable norm is the arithmetic mean of the unmasked conducting thresholds at 500, 1000, 2000 and 3000 Hz. If the equipment does not allow for measurement at 3000 Hz, the threshold at 3000 Hz per ear may be calculated on the basis of the average of thresholds at 2000 and 4000 Hz for the same ear. 2. Should the mean hearing loss exceed 40 db (HL) while speech can clearly be understood at 2 metres distance with each ear separately and without the use of a hearing-aid, hearing is considered to be sufficient. 15

17 Annex 3 16

18 17

19 Conditions for the designation as medical examiner for merchant shipping ANNEX 4 Having regard to Article 44 Seafarers Act and Article 110, seventh paragraph, of the Seafarers Merchant Shipping and Sailing Order, in addition to the requirements in Chapter 4 of the Seafarers Act, Chapter 6 of the Seafarers Merchant Shipping and Sailing Order and Chapter 7 of the Manning Order Deep-Sea Fishing, the following more detailed requirements are applicable to the designation as medical examiner for merchant shipping, as referred to in Article la, first paragraph. 1. A doctor can be designated as medical examiner when the following requirements are complied with: A. Competence, knowledge and skill 1. The doctor practicing in the Netherlands has been registered in the BIG register. The doctor practicing abroad produces a medicine license of the relevant country. Apart from that, a certificate of non-suspension signed by the competent authority of that country is produced. 2. The doctor has experience in recognizing diseases and disorders and has recent practical experience in overall physical examination and examination of the visual and auditory organs. The doctor is working in a relevant field of action in which the mentioned examinations are part of daily practice. 3. The doctor disposes of demonstrable knowledge of and experience in merchant shipping and is familiar with the living and working conditions on board of ships. 4. The doctor sufficiently masters the English or Dutch language in order to speak to the examinee, to carefully discuss the questions mentioned on the examination form with the examinee and to communicate with the Medical Advisor to the Head of the Shipping Inspectorate. B. Examination location and available equipment 1. A permanent location is available for the examinations which is easily accessible. 2. The examination room is clean, warm and adequately equipped with an examination bench and instrumentation. The conversation between medical examiner and candidate cannot be heard by others. For urine samples, the candidate can use a toilet with handwashing facilities. 3. For the determination of the remote visual acuteness, the close visual acuteness and the colour discernment, the examination material mentioned in Annex 2, item XXIII, or in Annex 6.1, Chapter 2, of the Inland Navigation Regulation is available, including at least the Ishihara test and one of the specialist colour tests with which the limit of a colour discernment disorder can be determined accurately. All examinations shall be capable of being carried out under the lighting prescribed for the relevant test. 4. A tone audiometer is available for determining the hearing acuity. The screening audiogram shall be capable of being taken in a very quiet environment through headsets. When an audiometry cabin cannot be disposed of, sound-insulating hoods, mounted over the headset, are available. The equipment is checked and calibrated by a competent body at least once a year. 5. The doctor has access to the internet and has an address that can be used for communication with the Medical Advisor to the Head of the Shipping Inspectorate. C. Need for examination capacity 1. An initial application by a doctor to be designated as medical examiner for merchant shipping in the Netherlands is only accepted when the need for examination capacity in the relevant regions allows it. The average number of examinations per doctor of the already designated doctors in the relevant regions has been at least 60 per year in the previous two years. 2. Contrary to the first paragraph, an initial application to be designated as medical examiner for merchant shipping in the Netherlands can be accepted when it concerns a succession of an already designated doctor who complied with the prescribed number of examinations as laid down in the third paragraph. 3. A renewed petition for designation as medical examiner for merchant shipping in the Netherlands is only accepted when the relevant doctor has performed on average at least 40 examinations for merchant shipping per year in the previous two years. The renewed petition for designation as medical examiner for merchant shipping is made at least three months before the time on which the designation ends. 4. An initial application by a doctor to be designated as medical examiner for merchant shipping outside the Netherlands is only accepted when the need for designation of a medical examiner in the relevant regions is demonstrated. The number of examinations to be expected by such a doctor is at least 100 per year. 5. A renewed petition for designation as medical examiner for merchant shipping outside the Netherlands is only accepted when the relevant doctor has performed on average at least 100 examinations for merchant shipping in the previous two years. The renewed petition for designation as medical examiner for merchant shipping is made at least three months before the time on which the designation ends.

20 D. Certificate of Good Conduct At the initial application to be designated as medical examiner for merchant shipping, the doctor produces a recent Certificate of Good Conduct. E. Publication of information The doctor assents to the entry of his name, address and telephone number on a list of available medical examiners, which is published on the internet and is sent upon request. As evidence of his assent, the doctor signs an assenting opinion. 2. The following requirements are related to the designation: A. Information medical examiner 1. The designation concerns an individual medical examiner. He is the only one who conducts the examination and signs the seafarer medical certificate with a signature and name stamp known by the Medical Advisor to the Head of the Shipping Inspectorate. 2. The designation concerns the conduct of examinations at a specified address. An intended change in the examination address is notified not more than three months before the time of change to the Medical Advisor to the Head of the Shipping Inspectorate. The Medical Advisor to the Head of the Shipping Inspectorate assesses whether the intended examination location complies with the requirements. 3. A change in administrative data or in the telephone number is immediately notified in writing to the Medical Advisor to the Head of the Shipping Inspectorate. B. Availability and accessibility 1. In general, the examinee is examined within one week after the request to that end. If the ship will depart within that period, the examining doctor exerts himself to conduct the examination before the time of departure or he refers the examinee to a colleague. 2. When the examinee makes an appointment for the examination, he gets clear information as to the route to the examination location. C. Assistance to supervision 1. The medical examiner renders all assistance to the Medical Advisor to the Head of the Shipping Inspectorate or his delegate in the event that he verifies whether all requirements have been complied with. 2. The medical examiner renders all assistance to the Medical Advisor to the Head of the Shipping Inspectorate or his delegate in the event of a random re-examination of an examinee. 3. The medical examiner gives the Medical Advisor to the Head of the Shipping Inspectorate the information of a conducted examination when he, authorized to that end by the examinee, requests this.

21 Conditions for the recognition as medical examiner for merchant shipping ANNEX 5 Having regard to Article 44 Seafarers Act and Article 110, seventh paragraph, of the Seafarers Merchant Shipping and Sailing Order, in addition to the requirements in Chapter 4 of the Seafarers Act and Chapter 6 of the Seafarers Merchant Shipping and Sailing Order, the following more detailed requirements are applicable to the recognition as medical examiner for merchant shipping, as referred to in Article la, second paragraph. 1. A doctor can be recognized as medical examiner when the following requirements are complied with: A. Competence, knowledge and skill 1. The doctor practicing in the Netherlands has been registered in the BIG register. The doctor practicing abroad produces a medicine license of the relevant country. Apart from that, a certificate of non-suspension signed by the competent authority of that country is produced. 2. The doctor has experience in recognizing diseases and disorders and has recent practical experience in overall physical examination and examination of the visual and auditory organs. 3. The doctor disposes of demonstrable knowledge of and experience in merchant shipping and is familiar with the living and working conditions on board of ships. 4. The doctor sufficiently masters the English or Dutch language in order to speak to the examinee, to carefully discuss the questions mentioned on the examination form with the examinee and to communicate with the Medical Advisor to the Head of the Shipping Inspectorate. B. Relation with managing owner 1. The doctor conducts medical examinations of seafarers for the benefit of a managing owner and has entered into an agreement to that end with the managing owner. 2. The agreement between the doctor and the managing owner guarantees the professional independence of the doctor. 3. The managing owner for whom the doctor conducts the medical examinations of seafarers, disposes of a quality system with which the supervision over the doctor is guaranteed. The quality system contains at least procedures with regard to: a. the medical examiners: 1. the overview of the doctors working for the managing owner as medical examiners; 2. compliance of the doctors working for the managing owner as medical examiners with the requirements, as referred to in the items 1, under A and E, of this Annex; b. the examination facilities: 1. the overview of the examination locations; 2. compliance of the examination rooms with the requirements, as referred to in item 1, under C, of this Annex; c. the examination process: 1. the conduct of the examination by the medical examiner in accordance with the requirements of this Regulation within the period as referred to in item 2, under B, sub 2, of this Annex; 2. the interpretation of the findings of the examination according to the medical standards, mentioned in Annex 2 to this Regulation; 3. the decision-making by the medical examiner as regards declaration of fitness or unfitness of the examinee in accordance with the general principles for declaration of unfitness, mentioned in Annex 1 to this Regulation, and the medical standards, mentioned in Annex 2 to this Regulation; 4. the registration by the medical examiner of the medical conclusions and the issue by the medical examiner of seafarer medical certificates and certificates of medical unfitness; d. the assistance by the medical examiner to supervision by the Medical Advisor to the Head of the Shipping Inspectorate or his delegate in accordance with item 2, under C, of this Annex; e. the administrative requirements, mentioned in item 2, under A, of this Annex; f. the communication between the managing owner and the medical examiner. 4. The quality system as referred to in the third paragraph is evaluated by the managing owner at least every two years. C. Examination location and available equipment 1. A permanent location is available for the examinations which is easily accessible. 2. When the doctor is working on a cruise ship or a passenger ship engaged on international voyages, contrary to the provision under 1, a permanent examination room on a specific ship is available. 3. The examination room is clean, warm and adequately equipped with an examination bench and instrumentation. The conversation between medical examiner and candidate cannot be heard by others. For urine samples, the candidate can use a toilet with handwashing facilities. 4. The doctor has access to the internet and has an address that can be used for communication with the Medical Advisor to the Head of the Shipping Inspectorate.

22 D. Need for examination capacity 1. An initial application by a doctor to be recognized as medical examiner for merchant shipping in the Netherlands is only accepted when the need for examination capacity allows it. The average number of examinations per doctor of the doctors already recognized for the benefit of the relevant managing owner has been at least 60 per year in the previous two years. 2. Contrary to the first paragraph, an initial application to be recognized as medical examiner for merchant shipping in the Netherlands can be accepted when it concerns a succession of an already recognized doctor who complied with the prescribed number of examinations as laid down in the third paragraph. 3. A renewed petition for recognition as medical examiner for merchant shipping in the Netherlands is only accepted when the relevant doctor has performed on average at least 40 examinations for merchant shipping per year in the previous two years. The renewed petition for recognition as medical examiner for merchant shipping is made at least three months before the time on which the recognition ends. 4. An initial application by a doctor to be recognized as medical examiner for merchant shipping outside the Netherlands is only accepted when the need for recognition of a medical examiner in the relevant region is demonstrated. The number of examinations to be expected by such a doctor is at least 100 per year. 5. A renewed petition for recognition as medical examiner for merchant shipping outside the Netherlands is only accepted when the relevant doctor has performed on average at least 100 examinations for merchant shipping in the previous two years. The renewed petition for recognition as medical examiner for merchant shipping is made at least three months before the time on which the recognition ends. E. Certificate of Good Conduct At the initial application to be recognized as medical examiner for merchant shipping, the doctor produces a recent Certificate of Good Conduct. 2. The following requirements are related to the recognition: A. Information medical examiner 1. The recognition concerns the examination of seafarers who perform (or will perform) another function than a function as referred to in Article 18, second paragraph, of the Act and who have no safety or security duties. 2. The recognition concerns an individual medical examiner. He is the only one who conducts the examination and signs the seafarer medical certificate with a signature and name stamp known by the Medical Advisor to the Head of the Shipping Inspectorate. 3. The recognition concerns the conduct of examinations at a specified address. An intended change in the examination address is notified not more than three months before the time of change to the Medical Advisor to the Head of the Shipping Inspectorate. The Medical Advisor to the Head of the Shipping Inspectorate assesses whether the intended examination location complies with the requirements. 4. A change in administrative data or in the telephone number is immediately notified in writing to the Medical Advisor to the Head of the Shipping Inspectorate. B. Availability and accessibility 1. In general, the examinee is examined within one week after the request to that end. If the ship will depart within that period, the examining doctor exerts himself to conduct the examination before the time of departure or he refers the examinee to a colleague. 2. When the examinee makes an appointment for the examination, he gets clear information as to the route to the examination location. C. Assistance to supervision 1. The medical examiner renders all assistance to the Medical Advisor to the Head of the Shipping Inspectorate or his delegate in the event that he verifies whether all requirements have been complied with. 2. The medical examiner renders all assistance to the Medical Advisor to the Head of the Shipping Inspectorate or his delegate in the event of a random re-examination of an examinee. 3. The medical examiner gives the Medical Advisor to the Head of the Shipping Inspectorate the information of a conducted examination when he, authorized to that end by the examinee, requests this.

23 5.2 Appendix A through E of the ILO/IMO guidelines 22