Seafarer's Medicals - ML5

Seafarer's Medicals - ML5

ML5 Seafarers Medical Form
This form is for use by the following applicants only. Please tick why you need this form/certificate:*

1. New applicant for an MCA Boatmaster's Licence (BML) or Certificate2. Revalidation or change of existing BML or Certificate3. Applicant for Royal Yachting Association (RYA) commercial endorsement, working no more than 60 miles from shore4. Crew on a seagoing Domestic Passenger Vessel (Class VI or VI(A))5. Master or Crew of a small commercial vessel certified for area category 2 to 66. Master or Crew of a fishing vessel under 24m*
7. Current ML5 has expired, used for:

BML:RYA Commercial Endorsement:Fishing Vessel under 24m*
Date of first BML / RYA endorsement or last revalidation (if applicable)

DayMonthYear
Date

Seafarer's Medicals - ML5

ML5 Seafarers Medical Form
Section 2 – Endocrine and Metabolic
Does the applicant have any of the following?:i) Endocrine disease (thyroid, adrenal including Addison's disease, pituitary, ovaries, testes)

YESNO
ii) Diabetes – non insulin, treated by diet alone*

YESNO
iii) Diabetes – non insulin, treated by oral medication*

YESNO
iv) Diabetes – insulin using*

YESNO

Seafarer's Medicals - ML5

ML5 Seafarers Medical Form
Section 9 - Other Medical Conditions/Additional Information
c) Is the applicant taking any medication that can impair safety duties?*

YESNO
(If yes, please specify medication in the box below)
d) Is the applicant taking any medication with risk of acute complications?*

YESNO
(If yes, please specify medication in the box below)*

Seafarer's Medicals - ENG1 | ML5