FORM / 4104/A
MEDICAL REPORT
| Report No: | ORIGINAL: TO MANAGERS COPY TO: DOCTOR, CREW AGENT, SHIPS FILE |
| PORT: DATE: | |
| THE BEARER OF THIS LETTER MP: | |
| WHO SERVES AS: | ON M/V: |
| COMPLAINS OF: | |
| Dear Doctor kindly examine above seaman and let us have your report below: The Master | |
| MEDICAL REPORT DIAGNOSIS: | |
| * MEDICATION GIVEN: YES NO | |
| * HOSPITALISATION: YES NO | |
| * REPATRIATION: YES NO | |
| Doctors Remarks: | |
| * FIT FOR HIS SERVICE: YES NO (FOR ABOUT _____ DAYS) NOTES: | |
| (PLACE AND DATE) | (SIGNATURE OF DOCTOR) |
| NOTE TO THE DOCTOR: THIS FORM IS TO BE COMPLETED, AND ORIGINAL TO BE RETURNED TO THE VESSEL. | |
| * = DELETE AS APPLICABLE |
STCW/95 Regulation
Section A-VIII/1
Fitness for Duty
1. All persons who are assigned duty as officers in charge of a WATCH or as rating forming part of a WATCH shall be provided a minimum of 10 HOURS of REST in any 24 hour period.
2. The hours of rest may be divided into no more than two periods, one of which shall be
AT LEAST 6 HOURS in length.
3. The above rest periods need not be maintained in the case of an emergency or drill
or in other overriding operational conditions.
4. The minimum period of ten hours may be reduced to not less than 6 consecutive hours privided that any such reduction shall not extend beyong two days and not less than 70 hours of rest are provided each seven-day period.
5. Administration shall require that watch schedules be posted where they are easily accessible.
REMARKS:
Updatet watch schedules to be posted in the Bridge, Engine Room and Mess Rooms.
FORM/4102 to be filled-in daily (one each day), and must be in compliance with the above
Watch Schedules
1. Completed FORMS are to be signed by the Master and Chief Engineer and are to bekept
2. in the ships file, easily accessible to any Authority.
3. In the above FORM insert ONLY personnel carrying out BRIDGE and ENGINE WATCH.
4. First two columns insert Rank and seafarers names.
5. Watch Keeping column insert the watch peroids and the used hours.
6. Other Work column insert working periods beyond the watches and the used hours.
7. Relaxation column insert the rest periods and the used hours.
Total Relaxation Hours
May be devided into TWO periods
One og the two periods shall be at least 6 consecutive hours in length.
Minimum relaxation must by minimum 10 Hours, which may be reduced to not less than 6 consecutive hours but shall not extend beyond two days and not less than 70 hours of rest each seven-days.
CERTIFICATE OF SERVICE
(Form 4109)
| Name of Vessel | Name of Seaman | Citizenship | Age |
| Official Number | Port of Registry | Rank | License number |
| Gross Tonnage Horse Power | Place of Engagement Date of Engagement | Total Service | |
| Nature of Voyage | Place of Discharge Date of Discharge |
(For the Office)
|
|
|
Name of Master Signature / Vessels Stamp
CERTIFICATE OF SERVICE
(Form 4109)
| Name of Vessel | Name of Seaman | Citizenship | Age |
| Official Number | Port of Registry | Rank | License number |
| Gross Tonnage Horse Power | Place of Engagement Date of Engagement | Total Service | |
| Nature of Voyage | Place of Discharge Date of Discharge |
(For the Office)
Name of Master Signature / Vessels Stamp
| : Ø 1 Ø 2 Ø 3 | |||
| : Ø 1 Ø 2 Ø 3 |
| , | |||||
| 20 | |||||
| ˸ | |||||
| 656,3 | 1,6444 | 1,5145 | 1,3311 | 1,5407 | |
| 589,3 | 1,6499 | 1,5170 | 1,3330 | 1,5443 | |
| 546,1 | 1,6546 | 1,5191 | 1,3345 | 1,5475 | |
| 480,0 | 1,6648 | 1,5235 | 1,3374 | 1,5665 | |
| 392,5 | 1,4844 | 1,892 | 1,7442 | 1,4235 |
