Roshan Marine Medical Centre- (Approved By D.G.Shipping Govt.

Of tndia)
Patna" gihar - Mob, 9793976032, 7753s89944 , Email td- [email protected]
SEAFARERIS MEDICAL EXAMINATION REPORT/CERTIFICATE
This certificate issued by authority of Maritime Administration and rn comptiance with the requirement of the Medi.at Examination(Seafarers)
Convention and the Maritime Labor Coweotien.2006
SURNAME SINGH NAME NIRAJ MI NAME SERIAL NO. 402
OF BIRTH
RANK AB GENDER Ma [e
HOME ADDRESS-
NAME. VESSEL NAME TYPE- INDOS- 12S12705
MEDICAL HISTORY. Please answer the of
Is there any past/present history ofany ol the Condidaters Examiner's Candidate's Examiner's
Declalatoion Declarat;on Declaratoion D€(laration
YES NO YES NO YES NO YES NO
Severe one-sided
Head injuryl Con(ussionl Loss of High/ Low Btood Disease

Vision Problem disease

Hearing Impairment disease
EAR/ Nose/Throat problem Addiction
Bowet Disorders Fractu re/ Dislocation/l niuru/ AmDutation
Stone Stone Disorder Majorl Minor op€ration
Jaundice/ Liver di:orders
Nervous

Female Dkorder signed off on medi(al ground/'De(lared

unit
EXAMINATION
HEIGHT IN CMS IN KGS BMI CHEST INSP.EXP. B.P. IN MM OF HG RESP GENERAL CONDITION
173CMS 77 KGS -ksln WNL 126/80 78/MtN 16/MlN GOOD
MEDICAL EXAMINATION

UNCORRECTED AUDIOMETRY H2 500 1000 2000 3000 4000 5000 8000

RIGHT EYE 616 616 Normal €ar DB WNL WfiL WNL 1r1,rNL WNL WNL WNL
LEFT 616 616 Normal Left Ear DB WNL WNL WNL WNL WNL }]lIN L WNL
VISION NORMAL Normal Normal Hearins Ear Left
OTHERS NormaI Nqrmal Normal Normat Normal
EXAMINATION NORMAL RESPIRATORY SYSTEM NORMAL
Head And Neck NORMAL Fissure/Fistuta/Piles NORMAL
NORMAL Veins
NORMAL FTT FOR SEASENUCT NORMAL
NORMAL

Muscte Skeleton
N€ruous
NORMAL
NORMAL
NORMAL
Ar AB Others NORMAL
NORMAL
NORMAL
Reflex NORMAL As Fer mLC-e06 vascular NCRMAL
S kin NORMAL
NORMAL

BLOOD RESULT RESULT TEST RESULT

13.1 GMo/o LIGHT YELLOW TOTAL
IOTAL WBC COUNT 6500 GRAVITY r..25
NEU 65 45-65 HDL CHOLESTEROL
LYMP 2a PROTTNE LDL NA
E0s 04 0-5 GLUCOSE VLDL CALCULAIEO NA
lt0No 03 3.9-s,6 BILIRUtsIN ABSENT NON.HDL CHOLESTEROL NA
PLATELATE 1.5-4.s NITRITE ABSENT
BLOOD SUGAR RANDOM 88.1 70-110170-140 UROBINOGEN ABSENT X RAY CHEST NA
M.p. R.B.C. ABSENT U5G NA
HIV I.'I NEGATIVE PUS CELL 1-3 KUB NA
HBSAG NEGATIVE EPITHELIAL 2-4 NA
ESR NA MM SGOT NA DENTAL NA
BLOOD GROUP NA NA DRUG OF ABUS€ NA
NA BILIRUBIN TOTAL NA PSYCHOI.OGICAI- NA
HBlAC
&l \
NA BILIRUBIN D'RECT NA SPIROMETNY t'lA
CREATI NIN E NA 0.3-1.3 MG/DL PHOSPHATESE NA
UREA
TJRIC ACID NA
NA 19-42 MG/DL
3.0-8.5
TOTAL PROTINE
ALBUMIN
NA
NA
Fatna ln
l6 I
i
CALCIUM NA 3.0-8.s MG/DL GLOBULIN NA Bihar dI
4

ON THE OF THE EXAMINEE HI5TORY DL Kumar DECLARE THE EXAMINEE MEDICALLY

PERMANENTI.Y TEMPORARI LY RECOMMENDED RE- EXAMINATION
FIT Day's
UNFIT UNFIT AFTER Week Moirths ''

REMARK/ I Dr- Surei xumrra.rirwi annexure.EandFof Examination rul€s 2000 in this certifidrte
This certificate i5 valid till :
Candidate's signature Place- Patna, Bihar Office Stamp

l*l ; ..

bl,B.B"S. RsS. No.-&S

Fatna
Bthar Mlan lJlarisrE ffisdtcel Csffs

sERucrffi Approved Ey D.& thhglng

Gov[ of lndia
AnBroval N o.8HR trf Nfi 38ffi2
 Apre.ndix- ru
Medical Certificate for Service at Sea

SINGH NIRAJ
(Seafarer's Last name, First name and Middle name)

a]-l07lL990 Male
Date of Birth(ddlmm/yyyy) Gender (Male/Female)

w0133829/MUM3741251-

(Number of PassportlcDC/other valid identification document-with type of document) :

has been examined byDR. Suraj Kumar
(Name of MedicaI Examiner)

And has been found fit for service at sea in the job of AB

{a) The hearing and sight of the seafarer concerned, and the colour vision in the case of a seafarer to be employed in capacities where fitness
for the work to performed is liable to be affected by defective colour vision, are all satisfactory,

(b) The seafarer concerned is not suffering from any medical condition tikely to be aggravated by service at sea or to render the seafarer unfit
fcr such service or to endanger the health of other persons on board.

{c} The seafarer complies with the requirements specified in Table A-l/9 of STCW Code(i.e, Minimum in services eyesight standards for
seafarers). Tabte B-l/9 of the STCW Code (1.e. Assessment of minimum entry [eve[ and in-services physicat abilities for seafarer) and
Regulation 1.2, Standard A-1.2 & Guideline B-1.2 of the MaritimeLabour Convention 2006.

1710U2024, Patna, Bihar

(Date & Place of Medical Examination) (Si
]t,nu'
o{t}e
g-nature M
!<tt m
ed ica t
a:-.t
Examiner)

t}r. Sural Kurmr

402 0[B.B.S. Rag.l*o.-tltr
(SeriaI number of the Certificate) Roshan Marine f#edcd Cilr
r\pr:roved Ey D.& thhphe
r, , ,,'' y*'l X[1dia
i., y i {}v iii Flo. "BHR FTilfl 3l,tg!ft2
:

(Address Contact No.

This Certificate expires on* 16/01/2025

( Day/Month/Yea r)*

(* Not more than 2 years from the date of issue, unless the seafarers is under the age of lS,in which case the of
the Medicat Certificate shall be 1 year).

lfthe period of validityof this the medical certificate expires in the coursb of voyage, the medicat certificate shall continue in force until the
next port call where an approved Medical Examiner is available and the seafarers can obtain a medical eertificate, provided that period of
such extension shall not exceed 3 months.
 APPsndix-v

SIGHT TEST CERTIFICATE

New Entryf?cdg!Ug:

Seria[/Reference No. 402

Full Name, NIRAJ SINGH

Rank. AB

PP/CDC/UID NO. w0133829/MUM374125/-

Date & Place of Birth 01/07i1990 1 KANNUJ

Colour of Eyes BLACK

ldentification Notes NONE

Right Eye Left Eye Both Eyes Result

Unaided 616 616 616 PASSED

Distance vision
Aided ,,'fte**S*d
Unaided 616 616 616 PASSED

Near Vision
Aided

Horizontal Plan NORMAL NORMAL NORMAL PASSED

Fie[d ofVision
Vertical Plan
lshihara NORMAL PASSED
Colour Vision
Lantern I Others

l,Dr. SslgjKumar herebycertifythattheabovementionedcandidatehasmet/notmet*,theeyesightstandardforhis/herdesignatedrankl

position as set out in Annex-ll* /Annex- lll" for seafaring occupation.

1.-irra+ ft*t-r rt'\ 4<ru"

Candidate's Signature
signature o(gf ftledicaI Examiner

17/01/2024, Patna, Bihar

(Date & Pla€e of Medicat Examination)

9at{re
'Brhar o
o
Apprqrcd BY D.C*
Govt of lndla
npproval Ho.8lffi fffNft

Note:

l. This certificate is valid for two ysaE from the above date. New entry sight teit certificates should be retained by the candidate tilt his active sea career.

2. Seafarer aggrieved by the decision of the Medical Examiner may appeaI as per the provision of the M.5. (Medical Examination] Rules, 2000 as amended'

3. * Delete if not appticabte,