Form Malta Medical Cek Up
Form Malta Medical Cek Up
Department
Deck Engine Radio Other Please specify:
Passport No. / Discharge Book No. / Identity Card No. Gender
Male Female
Address
Form TM/MSD/SCU 010 Issue 4 Transport Malta is the Authority for Transport in Malta set up by ACT XV of 2009
Additional questions: Yes No
35. Have you ever been signed off as sick or repatriated from a ship?
36. Have you ever been hospitalized?
37. Have you ever been declared unfit for sea duty?
38. Has your medical certificate ever been restricted or revoked?
39. Are you aware that you have any medical problems, diseases or illnesses?
40. Do you feel healthy and fit to perform the duties of your designated position /
occupation?
41. Are you allergic to any medication?
Comments:
Yes No
42. Are you taking any non-prescription or prescription medications?
If yes, please list the medications taken, and the purpose/s and dosage/s:
Applicant must sign personal declaration in the presence of a duly qualified medical practitioner who
will be filling PART B of this medical report
I hereby certify that the personal declaration above is a true statement to the best of my knowledge.
Furthermore, I authorize the release of all my records from any health professionals, health institutions and
public authorities to the appointed medical practitioner.
Applicant`s Signature
(Signed in the presence of medical practitioner) Date:
PART B – To be completed by a duly qualified medical practitioner
Medical Examination
Height (cm) Weight (kg) Pulse Rate / (minute) Rhythm
Blood pressure (mm HG) Urinalysis
Systolic Diastolic Glucose Protein Blood
Sight (Table on the “Minimum in-service eyesight standards for seafarers” is found on page 4 of this medical report)
Use of glasses or contact lenses: Yes No
Visual acuity Visual fields
Unaided Aided
Right eye Left eye Binocular Right eye Left eye Binocular Right eye Left eye
Distant Normal
Near Defective
Colour vision Not tested Normal Doubtful Defective
Hearing
Pure tone and audiometry (threshold values in dB) Speech and whisper test (metres)
500 Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz 6000 Hz Normal Whisper
Right ear Right ear
Left ear Left ear
Results:
Department
Deck Engine Radio Other Please specify:
Passport No. / Discharge Book No. / Identity Card No. Gender
Male Female
This is to certify that I have examined the applicant and that my findings are recorded in this medical
report
Result:
Fit for Sea Duty Unfit for Sea Duty **Fit with limitations or restrictions
Applicant`s Signature
Signature of duly qualified medical practitioner (Signed in the presence of medical practitioner)
Validity
This medical certificate shall remain valid for a maximum period of two years unless the seafarer is under the
age of 18, in which case the maximum period of validity shall be one year.
All data collected in this form is processed in accordance with the Privacy Laws that include General Data Protection Regulation
(Regulation 2016/679/EU) and Chapter 586 of the Laws of Malta (Data Protection Act). The data provided may be exchanged with other
Public Authorities and/or Government Departments as required and permitted by Maltese Law. Transport Malta of Triq Pantar, Lija,
Malta LJA2021 is the data controller for the purpose of the privacy laws. The Privacy Notice attached with this application sets out the
way in which personal information/data is collected and processed by Transport Malta, as well as the steps that are taken to protect
such information.
Transport Malta of Triq Pantar, Lija, Malta LJA2021 is the Data Controller for the purpose of the General Data Protection Regulation
(EU) (GDPR) 2016/679 and Data Protection Act CAP. 586. This Privacy Notice sets out the way in which we collect and process your
Personal Information, as well as the steps we take to protect such information.
1.2. The primary purpose for collecting information is mainly to process the application for seafarer documentation/certification,
however, your Personal information may also be used for related purposes that amongst others include: communicating
notifications, communication strictly related to the document applied for/in hand and for the provision of information with regards to
any legislative amendments which may affect the services offered to you.
5. Security
5.1. We take appropriate security measures to protect against loss, misuse and unauthorized access, alteration, disclosure, or
destruction of your information. Additionally, steps will also be taken to ensure the ongoing confidentiality, integrity, availability,
and resilience of systems and services processing personal information, and will restore the availability and access to information
in a timely manner in the event of a physical or technical incident. All information gathered is kept confidential and is used solely
for the Seafarer Document/Certificate purposes.
5.2. If we learn of a security systems breach, we will inform you of the occurrence of the breach in accordance with applicable law.
6. Governing Law
All data collected in this form is processed in accordance with the Privacy Laws that include General Data Protection Regulation
(Regulation 2016/679/EU) and Chapter 586 of the Laws of Malta (Data Protection Act).
7. Data Protection Officer
7.1. Transport Malta has a Data Protection Officer (“DPO”) who is responsible for matters relating to privacy and data protection. The
DPO can be reached at the above address or by email: [email protected]
8. Contacting us
8.1. Please address any questions, comments and requests regarding the application process to: [email protected]