CG-719K Physical

All fields must be thoroughly verified and ensure they are filled out correctly and completely.

 

IMPORTANT NOTES FOR SECTIONS/FIELDS

* The top of nearly each page must have the mariner’s name – LAST, FIRST MI and Date of Birth: MM/DD/YYYY

* The bottom right-hand corner of each page must be initialed and dated by the Physician

 

Section I (Page 3) – Make sure all info is accurate.

Endorsement Sought – Typically “DECK” “FOOD HANDLER” “ENTRY LEVEL WITH LOOKOUT DUTIES”

 

Section II (Page 3) – Physician must mark the appropriate box

Section III(a) (Page 4) – Look for check mark in “Medical Waiver” question

Look for check mark in all boxes as needed. (“PR” is previously reported and is only used for a renewal mariner)

Section III(b) (Page 5) – Physician must complete this section. All items with check mark in “Yes” on page 4 must be noted and explained.

Section IV (Page 6) – Look for check mark in “Do You Use Medications?”

Applicant may fill in medications, but Physician must comment on each as required.

Section V (Page 6) Look for required info in each box for vitals

Look for check mark in all boxes for items 1-16

Section VI(a) (Page 7) Look for uncorrected vision for ALL applicants. If the applicant wears glass, there MUST be a corrected vision.

Field of Vision: check mark as appropriate

Section VI(b) (Page 7) Color Vision - Look for check mark in type of test taken. A box MUST be checked.

Look for check mark in “Testing Results” Number of Errors MUST be filled in.

Section VII (Page 7) Hearing - Look for check mark in “Normal Hearing” for most applicants. A hearing test is not required for normal hearing.

Section VIII (Page 8) Physical Ability - Look for check mark in “Physical Ability Results”

Section IX (Page 9) Summary - Look for check mark in parts (a), (b), & (c)

Part (d) Review physician comments, if any.

Part (e) Medical Practitioner – ALL information must be completed. Make sure Physician Signature is in correct space!

Section X (Page 9) Applicant Certification – make sure it is signed by the Applicant (Not the physician) and dated on the date of physical exam (Not DOB)

Section XI (Page 10) Applicant Consent – part (a) must be signed and dated or check mark “Declined”