MSF 4112 Rev 0818

Seafarer Medical Report

(ML5) and ML5 Certificate

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 Certificate

2. Revalidation or change of existing BML or Certificate

3. Applicant for Royal Yachting Association (RYA) commercial endorsement,

working no more than 60 miles from shore
4. Crew on a seagoing Domestic Passenger Vessel (Class VI or VI(A))

5. Master or Crew of a small commerical vessel certified for area category 2 to 6

6. Current ML5 has expired, used for:

BML RYA Commercial Endorsement

Note: Boatmasters working as a Master on a seagoing passenger ship require a full seafarer medical certificate (ENG
1) following examination by an MCA Approved Doctor. An ENG 1 is always an acceptable alternative to an ML5
certificate. Details of the procedure for obtaining an ENG 1 and a list of Approved Doctors is available in a Merchant
Shipping Notice and can be consulted on the GOV.UK webpage at: https://www.gov.uk/guidance/seafarers-
medical-certification-guidance.

If you are unclear on what type of medical fitness certificate you need please refer to our website at
https://www.gov.uk/guidance/seafarers-medical-certification-guidance or call us on 0203 81 72835.

TO THE APPLICANT – PLEASE READ THIS INFORMATION CAREFULLY

Please take a form of photographic identification with you to the ML5 Medical examination.

The purpose of the ML5 form is to obtain a factual report of your medical history and present state of health, enabling
your doctor to decide on your fitness to navigate safely and undertake emergency duties.

Complete Part A of the form (but do not sign the declaration until you are with the doctor). The Doctor will complete
Part B. If Part B shows all ticks in the "NO" boxes without any other remarks then the doctor will complete Part C, the
ML5 Medical Certificate. This certificate confirms you are medically fit to hold a BML, RYA commercial endorsement
or to work on vessels listed on this form. Once both the report and certificate have been completed, please take/send
both to your local MCA Marine Office or RYA for the commercial endorsement as necessary. If you do not require a
commercial endorsement, just keep your ML5 certificate ready for inspection when requested.

However, if you have a tick in any of the "YES" boxes on the inside of this report, or if you have any medical conditions
noted in Section 9, your report will require further assessment by an MCA ML5 Medical Assessor. Your local MCA Marine
Office or RYA (depending on what you wish to use your ML5 certificate for) can refer your report form to an MCA ML5
Medical Assessor once you have completed Part D – Medical Review. Please do not send your ML5 report directly to
MCA Seafarer Safety and Health Team or your previous ML5 Medical Assessor, this will delay your application. If
you are unclear on where you should send your form please call us on 0203 81 72835.

RYA applicants are advised to be medically assessed before starting any training, to ensure they meet the fitness and
eyesight standards.

If you are based abroad and no UK GMC registered medical practitioner (holding a valid license to practice) is
available, you are advised to obtain an ENG 1 certificate (or recognised equivalent) issued by an Approved Doctor;
lists of Approved Doctors and recognised equivalent certificates are available on the MCA website as above.

I authorise my doctor(s) and specialist(s) to release reports/medical information about my condition relevant to my
fitness, to the MCA Medical Assessor. I authorise the Secretary of State to disclose such relevant medical information
as may be necessary to the investigation of my fitness, to my doctor/s and MCA Medical Assessors.
You MUST stop working if you become unfit due to illness or injury during the validity of your ML5 certificate. Even if this is a
temporary change you are obliged to tell the issuing authority (MCA or RYA). For instance, if you have diabetes and your treatment
Page
changes from diet or tablets to insulin, you must immediately cease1 work
of 14and inform the issuing authority. You will need to obtain a
new4112
MSF ML5 report
/ REVand be medically reassessed before your license can be reinstated. If you fail to do so, your medical certificate will
0818
automatically be suspended.
 PART A – PERSONAL DETAILS

Surname ______________________________ Forename(s) _________________________________

Home
_______________________________________________________________________________
Address
_______________________________ Postcode ___________________________
Gender Male / Female (*delete as applicable) Date of Birth _________________________________
Telephone
Nationality
Number _______________________________ _________________________________
Mobile Email
Number _______________________________ address _________________________________
Date of first BML/RYA endorsement or last revalidation
(if applicable) ______________________________________________
Have you had an ML5 referral or restriction before? (if
yes please provide issues & expiry dates and restriction/s) ______________________________________________

YOU MUST SIGN THIS DECLARATION WHEN YOU ARE WITH THE DOCTOR WHO WILL BE FILLING IN PART B OF THIS
FORM

I declare that I have checked the details given on the enclosed form and that, to the best of my knowledge and belief,
they are correct. I understand that it is a criminal offence if I make a false declaration to obtain certification and can
lead to prosecution. I have read the notes on the reverse of the certificate (page 12).

Signature of Applicant ___________________________________________ Date ________________

NOTES FOR THE DOCTOR – Please read this information carefully

As the Doctor you must sign and date the declaration on page 8 when you and/or the Optician has completed the report.
Only qualified medical practitioners fully registered and holding a valid UK Licence to Practice with the General Medical
Council are permitted to complete this form. Please ensure that you confirm the applicant’s identity before examination.
We have advised the applicant of the need to produce photographic identification.

Vision Assessment: Only complete the vision assessment if you are able to fully and accurately complete all the
questions. If you are unable to do this, you must advise the applicant of this and advise them to arrange to have this
part of the assessment completed by an optician or optometrist.

Medical Report: This medical report and certificate is required for applicants who intend to work on commercially
operated boats including passenger boats, either on inland waters or at sea up to 60 miles from shore. Therefore, in
completing the form, please be aware of the applicant's work environment and responsibilities.

Routine duties could include: Emergency duties could include:

• navigating the boat safely • rescuing persons from the water
• safely berthing and unberthing the boat • tackling a fire
• helping passengers on and off the boat • provision of first aid
• moving and lifting objects up to 30kg • carrying out an evacuation of the boat
• operating winches and handling ropes • climbing in and out of a liferaft at sea
• climbing access ladders

Be aware that the safety of fare paying passengers may depend on the fitness of the applicant to operate the vessel in
adverse sea and weather conditions. They need also to be capable of responding reliably and effectively to
emergencies such as breakdown, collision or capsize that call for physical and mental resilience. The applicant should
therefore not be subject to any increased likelihood of sudden incapacity that could prevent them returning the boat
safely to its moorings.

You should establish the nature of the duties undertaken, as these may vary from work on calm inland waterways to
the open sea. The vessel may have a number of crew members or the applicant may be the sole competent person
on whom the safety of passengers depends.

You must examine the applicant fully and complete sections 1 – 10 of the medical assessment. Please obtain details
of the applicant’s medical history when you complete the report.

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MSF 4112 / REV 0818
IF HAVING COMPLETED THE FOLLOWING REPORT THERE ARE NO TICKS IN A "YES" BOX AGAINST ANY OF THE
QUESTIONS, AND YOU HAVE NO OTHER MEDICAL CONCERNS, PLEASE COMPLETE THE CERTIFICATE PROFORMA AT
PART C AND RETAIN A COPY FOR VERIFICATION PURPOSES. OTHERWISE PLEASE LEAVE THE CERTIFICATE BLANK.

Once you have completed the report please return both the report and certificate (if you have issued one) to
the seafarer. If any medical concerns are indicated on the form, you may be contacted in due course by an MCA
Medical Assessor.

If you have any questions regarding the completion of this medical report please contact us on 0203 81 72835
or by email at seafarer.s&[email protected]

PART B – MEDICAL REPORT

Tick as appropriate
Section 1 – Cardiac
Coronary Heart Disease
a) Is the applicant having attacks of angina of effort, or receiving YES NO
continuous treatment to prevent angina from manifesting itself?

b) Has the applicant had myocardial infarction, unstable angina, or YES NO

undergone coronary artery bypass surgery or coronary angioplasty?

If YES – please answer the following:

i) What was the nature of the event? ____________________________________________________________

ii) When was the most recent episode? __________________________________________________________

iii) If the applicant remains on medication, give details _______________________________________________
__________________________________________________________________________________________
iv) Give details of any continuing symptoms / clinical signs of heart disease ______________________________
__________________________________________________________________________________________
Arrhythmias
c) Has the applicant uncontrolled complete heart block? YES NO

d) Has a cardiac pacemaker been implanted? YES NO

If YES, when did the applicant last attend a pacemaker clinic? D D M M Y Y

e) Has a cardioverter / defibrillator device been implanted? YES NO

f) Is there currently a serious or disabling disturbance of cardiac rhythm, such YES NO
as atrial fibrillation?
g) Is the applicant in need of medication to prevent paroxysmal arrhythmia? YES NO
Other
h) Is there evidence of serious congenital heart disease requiring continuing YES NO
consultant cardiological review?

i) Is there any history or evidence of heart failure or cardiomyopathy? YES NO

j) Has the applicant undergone heart transplant or heart / lung transplant therapy? YES NO
k) Has the applicant evidence of an aortic aneurysm that has not been successfully YES NO
treated by surgery?

l) Is today’s resting systolic blood pressure 170mm Hg or greater? YES NO

m) Is today’s resting diastolic blood pressure 100mm Hg or greater? YES NO
n) Is there any history of stroke? YES NO
o) Is there any history of Deep Vein Thrombosis? YES NO

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 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) YES NO
ii) Diabetes – non insulin, treated by diet alone YES NO
iii) Diabetes – non insulin, treated by oral medication YES NO
iv) Diabetes – insulin using YES NO
v) Obesity – BMI over 35 YES NO
Please write BMI here (including BMIs of under 35) ___________________________

Section 3 – Nervous System

a) Has the applicant had any form of epileptic attack? YES NO

i) If YES, please give details of last attack _________________________________

ii) Is the applicant still being treated? YES NO

iii) If NO, please give the date when treatment ceased D D M M Y Y

b) Is there a history of blackout or impaired consciousness within the last 5 years? YES NO
If YES, please give dates and details in Section 9.

c) Does the applicant have narcolepsy/cataplexy or any obstructive sleep apnoea? YES NO
If YES, please give dates and details in Section 9

d) Is there a history of, or evidence of any of the conditions listed 1-8 below?
If YES, please give dates and details in Section 9.

(1) TIA YES NO

(2) Sudden and disabling dizziness/vertigo within the last year with a liability to recur YES NO
(3) Subarachnoid haemorrhage YES NO
(4) Serious head injury within the last 10 years YES NO
(5) Brain tumour, either benign or malignant, primary or secondary YES NO
(6) Other brain surgery YES NO
(7) Chronic neurological disorders e.g. Parkinson’s disease, Multiple Sclerosis YES NO
(8) Dementia or cognitive impairment YES NO

Section 4 – Psychiatric Illness

a) Is there a history of, or evidence of any of the conditions listed in 1-6 below?

If YES, please give details including date(s), prognosis, period of stability and details of medication, dosage and
any side effects in Section 9. N.B. If applicant remains under specialist care ensure details are given in Section 9.

(1) A psychotic illness in the past 5 years YES NO

(2) A neurotic illness (anxiety/depression) in the past 5 years YES NO
(3) Persistent alcohol misuse in the past 12 months YES NO
(4) Alcohol dependency in the past 3 years YES NO
(5) Persistent drug misuse in the past 12 months YES NO
(6) Drug dependency in the past 3 years YES NO
(7) Disorder of personality (clinically recognised) YES NO
(8) Any other mental health and cognitive disorders YES NO
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MSF 4112 / REV 0818
 Section 5 - Sensory

Vision Assessment
To be completed by a doctor or optician/optometrist
Seafarer’s Details
Surname: ________________________________ Forename(s): __________________________________

Date of Birth: _____________________________ Photo ID Checked: (please tick to confirm you have checked the photo ID)

The purpose of the vision test is to ensure that the seafarer is able to reach the minimum standards of acuity and their colour
vision shows no red/green deficiency. Colour vision should be tested using either 24 or 38 Ishihara plates. If the applicant fails
on the first attempt, please retest once, does not pass on retest, then to be considered as a fail.
Applicants who fail the Ishihara colour plate test may take this report to one of the MCA CAD test centres as listed in MIN 564,
for a CAD test.

24 PLATE TEST: 2 errors or fewer – PASS 38 PLATE TEST: 3 errors or fewer – PASS
5 errors or more – FAIL 6 errors or more – FAIL
3 or 4 errors – RETEST 4 or 5 errors – RETEST

a) Did the applicant fail the Ishihara colour plate test YES NO
When testing, please ensure that aids to colour vision are not being worn.

b) Does the applicant lack the ability to read 6/6 on the Snellen chart at 6 metres distance YES NO
in at least one eye with glasses or contact lenses if worn? Testing should be done on each
eye separately.

c) Does the applicant lack the ability to read 6/60 with at least one eye without any visual YES NO
aid? Testing should be done on each eye separately.

For all applicants record the visual acuity of each eye

Uncorrected Corrected (if necessary)
Right Left Right Left
6/____ 6/____ 6/____ 6/____

d) Has the applicant any defects in their field of vision in either eye? YES NO
If YES, please give details in Section 9.

e) Is there evidence of any progressive disease in either eye? YES NO

If YES, please give details in Section 9.

f) Does the applicant have any other eye condition which could limit vision, either now or YES NO
within the next 5 years? If YES, please give details in Section 9.

You must sign and date this section. Doctor/Optometrist/Optician

Stamp:
Name of examining Doctor/optician (print)
_______________________________________________________
Signature of examining Doctor/optician
________________________
Date of signature D D M M Y Y
Your GOC, HPC or GMC Number ____________________________

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MSF 4112 / REV 0818
 Section 5 – Sensory (continued)
g) Is there deafness that significantly impairs communication by radio or telephone? YES NO

Section 6 – Malignant Disease

a) Does the applicant have any malignant disease likely to impair physical or mental fitness YES NO
to undertake duties in the foreseeable future?

b) Is there a history of bronchogenic carcinoma or any other malignant tumour (e.g. YES NO
malignant melanoma) with a significant liability to metastasise cerebrally?

If YES, please give details including date(s), diagnosis and whether there is current evidence
of dissemination – in Section 9.

Section 7 – Musculoskeletal Limitations

Height (m) Weight (kg)

a) Does the applicant lack the strength and flexibility needed to:
i) perform their normal duties such as mooring and lock operations? YES NO
ii) physically assist other people who have fallen overboard or who need to evacuate YES NO
the vessel in an emergency?

b) If the applicant works at sea, do they lack strength and flexibility to get in and out of a YES NO
moving life raft? Leave blank if not applicable.

c) Is the applicant’s build likely to interfere with the activities listed above or prevent access YES NO
to areas of the vessel with limited space? If YES please give details in Section 9.

d) Is there currently any disability of the spine, limbs or hands likely to limit duties or safety YES NO
procedures while working?

e) Has the applicant had a knee/hip replacement or other limb prosthesis? YES NO

f) Does the applicant lack sufficient fitness to be responsible for the safety of fare paying
passengers (if applicable)? YES NO

Section 8 – Respiratory System

a) Is there a history of, or evidence of any of the following:

i) Sinusitis/Nasal Obstruction YES NO
ii) Chronic Bronchitis and/or Emphysema YES NO
iii) Pneumothorax YES NO

Please continue to the next page >

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MSF 4112 / REV 0818
 Section 8 – Respiratory System (continued)

8 a) iv) Asthma

Please ensure you read the MCA asthma definitions below before answering the questions.

Mild asthma – frequent episodes of wheezing requiring use of beta agonist inhaler or the introduction of a
corticosteroid inhaler. Regular use of a preventer inhaler may effectively eliminate symptoms and the need for
more than occasional use of a rapid acting bronchodilator reliever inhaler.

Exercise or cold induced asthma – episodes of wheezing and breathlessness provoked by exertion especially
or cold. Episodes may be effectively controlled by either long-term preventer inhalers, short term reliever inhalers
used prior to or during exercise or by oral medication.

Moderate asthma – frequent episodes of wheezing despite regular use of inhaled steroid (or steroid/long acting
beta agonist) treatment requiring continued use of frequent beta agonist inhaler treatment, or the addition of other
medication, occasional requirement for oral steroids.

Severe asthma – frequent episodes of wheeze and breathlessness, frequent hospitalisation, frequent use of oral
steroid treatment.

Does the applicant have:

If the answer is YES to any of the below, please provide details in section 9.

a) History of severe childhood asthma with any symptoms at all present during YES NO
the last five years?

b) Exercise or cold induced asthma? YES NO

c) Mild asthma that requires treatment with bronchodilator reliever inhalers (either YES NO
alone or to supplement regular use of preventer inhalers) on more than two days
a month?

d) Moderate or severe asthma as an adult? YES NO

e) Any hospital admissions over the last three years (due to asthma), or had oral steroid YES NO
treatment for asthma during the last three years?

Please continue to the next page leaving the space below blank >

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MSF 4112 / REV 0818
 Section 9 – Other Medical Conditions/Additional Information

If you have ticked YES to any of the above questions or have written in the boxes below and so are not able to
issue a certificate, this form will be referred to one of the MCA’s Medical Assessors.

a) If you have ticked YES to any of the questions, please look at the job requirements noted in Part B on page 2
and, you consider that there is any additional information which could help the Assessor, for instance about the
nature of any treatments, prescribed medications, frequency and severity of condition, any associated risk
factors or any indicators of prognosis, please give details below.

b) If the applicant has a medical condition not included in the list of questions, please look at the job requirements
noted on page 2 and, if you consider it may have any effect on their ability to meet these, please give details
below.

c) Is the applicant taking any medication that can impair safety duties? YES NO
(If yes, please specify medication in the box below)
Examples:
Has a warning in the product information leaflet indicating that they should not drive or work with moving
machinery
Psychoactive: Sleeping tablets, medications for mental health problems, sedating antihistamines (OTC or
prescribed)
May increase risk of sudden incapacitation: insulin
May impair vision: hyoscine

d) Is the applicant taking any medication with risk of acute complications? YES NO
(If yes, please specify medication in the box below)
Examples:
Increases risk of bleeding: warfarin
Danger if medications stopped: replacement hormones/insulin, anti-convulsants, anti-hypertensives, oral
antidiabetics
Anti-infection agents
Anti-metabolites and cancer treatments
Medications supplied to be used for emergencies: asthma, allergy

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 Section 10 – Declaration by Examining Doctor

I certify that I am fully registered and hold a valid Licence to Practice with the UK General Medical Council, I have
examined the applicant named in PART A and that my findings are recorded above in PART B of this report.

Please tick a, b or c as appropriate.

a) There are no ticks in any “YES” box and I have completed the ML5 certificate proforma at PART C
and retained a copy.
b) There are ticks in “YES” boxes in Section 1 – 8, so I have not issued the ML5 certificate.
c) There is any other significant medical condition detailed in Section 9, so I have not issued the ML5
certificate

Date of Examination D D M M Y Y
OFFICIAL STAMP

GMC Number
Signature of
Examining Medical
Practitioner

Name (print)

Address (print)

Telephone Number

Are you the applicant’s General Practitioner? YES NO

Usual Medical Practitioner or Medical Advisor (if different from above)

Full name

Address

County

Postcode

PART C – ML5 Certificate

Notes for the completion of Part C

1. If you have not ticked any “YES” box in Part B of this form and have not made comments in Section 9,
please complete the following certificate proforma at Part C, OTHERWISE IT SHOULD BE LEFT
BLANK.
2. A copy of the certificate should be retained by the Doctor for verification purposes.

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 This page is left intentionally blank

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 ML5 CERTIFICATE OF FITNESS
based on the
MARITIME AND COASTGUARD AGENCY ML5 REPORT

This is to certify that:

Surname

Forename(s)

Date of Birth

Home Address

Post Code

has been assessed by me for medical fitness in accordance with the criteria specified by the Maritime and
Coastguard Agency (MCA) in the ML5 form and all assessment ticks are in the “NO” Box (right hand column). I
have not included any comments affecting fitness in Section 9.

A practical test of capability for current duties has not been carried out.
Doctors Official Stamp

Signed (Medical
Practitioner)

Name (Block Letters)

Address

Postcode
This certificate is valid until*

D D M M Y Y
*maximum 5 years from date of issue or 65th birthday, whichever comes soonest. 1 year for those over 65 years of age

Date issued GMC Registration Number

Name of RYA / MO
Endorsing Officer** RYA or MO Stamp

** Endorsement is only required for those applying for a BML or RYA

endorsement

Signature

Signature of Holder

Date

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MSF 4112 / REV 0818
 MSF 4112 / REV 0317

NOTES TO THE HOLDER OF THIS CERTIFICATE

It is your personal responsibility not to work when you are temporarily

unfit to do so because of illness or injury. You must therefore tell the
issuing authority (MCA or RYA), if during the validity of your ML5
certificate, you suffer from or develop any of the following:

a) a serious health problem or injury where you do not fully recover;

b) any of the conditions listed below:

• epileptic seizures or sudden disturbances of consciousness

• myocardial infarction (heart attack) or heart surgery
• problems with heart rhythm
• disease of the heart or arteries
• uncontrolled blood pressure
• diabetes requiring insulin treatment
• stroke or unexplained loss of consciousness
• head injury with continuing loss of consciousness
• Parkinson’s Disease or Multiple Sclerosis
• mental or nervous problems including anxiety or depression
• alcohol or drug dependency problems
• profound deafness
• serious deterioration in vision or long term eye disease

c) any other disability or illness (mental or physical) which affects your

fitness to work, in particular to navigate safely and to be able to
undertake emergency duties. For instance if you have diabetes and
your treatment changes from diet or tablets to insulin.

Your BML/RYA endorsement will not be valid during your illness and
you will need to obtain a new ML5 report/certificate once you have
recovered in order for your licence to be reinstated.

Those not requiring a BML or RYA Endorsement do not need to have

their ML5 certificates endorsed by the RYA or MCA Marine Office, but
should retain them for inspection as necessary, noting the validity.

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MSF 4112 / REV 0818
 PART D – MEDICAL REVIEW – to be completed by the APPLICANT (where appropriate)
Notes for the applicant - Incomplete or missing information will delay your application. ANY FORM SENT FOR
REVIEW SHOULD NOT BE MORE THAN 3 MONTHS OLD AT THE TIME OF APPLICATION.

1. If there are ticks in any “YES” box in Section B, or if the Doctor has made remarks in Section 9, they cannot complete the
ML5 certificate, and the MCA Marine Office/RYA cannot issue your BML/RYA endorsement. However, in these
circumstances you have the right to have your case reviewed and the MCA Marine Office or RYA (only for RYA
Commercial Endorsement applicants), can refer your form to an MCA Medical Assessor for a decision based on your
fitness to undertake your work on a boat.

2. For the purposes of medical review, you may wish to provide further information regarding your fitness to hold a BML/RYA
endorsement. This may include medical evidence from your GP, a specialist consultant or optometrist as appropriate. Medical
evidence should be submitted with this form to your local MCA Marine Office or the RYA in an envelope marked “Private and
Confidential” for forwarding to the MCA ML5 Medical Assessor.

3. The Medical Assessor may speak to your GP or specialist, rather than requesting written reports for which you would have
to pay. Telephone calls often allow for evaluation of your health issues and the nature of your work.

4. Based on the evidence you have provided the MCA Medical Assessor will decide whether or not to issue an ML5 medical
certificate. It will then be for the MCA Marine Office/RYA to decide whether the BML/RYA endorsement can be issued.

Details of vessel To Sea Categorised Waters

Type of Vessel Vessel Size
Up to miles from point of departure

Proposed area of operation Up to miles offshore

Longest length of trip * mins/hours/days/weeks/months (*delete as applicable)

Operational at night YES / NO (*delete as appropriate)

Area of operation (including

category)

Type of operation involved (e.g.

passenger pleasure trips, fish
farm supplies, etc.)
Other relevant risk factors (e.g.
communications with shore
based staff, nature of
passengers, etc.)
Holders of BMLs Additional crew with same qualifications
Minimum Number of Crew (other
than applicant) Unqualified but trained/experienced crew Trainees/others

Passengers (where applicable) Maximum number of fare-paying passengers

Medication (please list all

prescribed medication you are
currently taking including
dosage), or write ‘None’ if
appropriate

Details of any regular

review/monitoring of condition

GDPR Privacy Notice: If your ML5 Report form is referred to an ML5 Medical Assessor the personal information collected on
this form will be shared with the Maritime and Coastguard Agency (MCA) for them to fulfil their statutory duties under Merchant
Shipping (Maritime Labour Convention) (Medical Certification) Regulations 2010. MCA will be notified of the ML5 Assessor's
final decision. An anonymised record containing this information and the ML5 Assessor's rationale for the decision will be
completed by the Assessor and submitted to MCA for audit purposes. For further information on how the MCA handle your
personal information please see our full privacy statement at www.gov.uk/mca

I authorise my doctor(s) and specialist(s) to release reports/medical information about my condition relevant to my
fitness, to the MCA Medical Assessor. I authorise the Secretary of State to disclose such relevant medical information
as may be necessary to the investigation of my fitness, to my doctor/s and MCA Medical Assessors.

Signature of Applicant __________________________________________ Date _____________________________

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 PART E – CONTINUATION BOX

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