AGOLL VENTURES LIMITED

MEDICAL FITNESS CERTIFICATE

1. LAST NAME OF PERSONNEL

2. FIRST NAME

3. MIDDLE INITIAL

4. DATE OF BIRTH

5. PLACE OF BIRTH

6. SEX

MONTH / DAY / YEAR

CITY

COUNTRY

7. EXAMINATION OF DUTY AS:

MALE

FEMALE

8. MAILING ADDRESS OF PERSONNEL

CRANE OPERATOR OFFSHORE

ELECTRICIAN OFFSHORE
MACHINIST

RIGGER
RIGGER FOREMAN
WELDER

Email:

MECHANIC OFFSHORE
NDT OPERATOR
PIPE FITTER

MEDICAL EXAMINATION
9. HEIGHT

15.

(TURN OVER FOR MEDICAL REQUIREMENTS)

10. WEIGHT

VISION:

11. BLOOD PRESSURE

RIGHT EYE

LEFT EYE

STATE DETAILS ON REVERSE SIDE

12. PULSE

16.

13. BREATHING

14. GENERAL
APPEARANCE

HEARING

WITHOUT GLASSES
. WITH GLASSES

17. COLOR

RIGHT EAR __________________ LEFT EAR_________________

TEST TYPE: BOOK

LANTERN COLOR TEST: YELLOW______ RED______ GREEN_____ BLUE______

18 HEAD AND NECK

___________________________________________

19. HEART (CARDIOVASCULAR)

___________________________________________

20.LUNGS____________________________________________

21. SPEECH (RADIO OFFICER):

Is speech unimpaired for normal voice communication?
________________________________________________________________________________________________________________________
22. EXTREMITIES:

UPPER______________________________________ LOWER __________________________________

23. Is personnel suffering from any disease likely to be aggravated by, or to render him unfit for service at sea or likely to endanger the health of other persons on board?

_______________________________________________
SIGNATURE OF PERSONNEL
This signature should be affixed in the presence of the examining Physician
24. THIS

___________________
MONTH/DAY/YEAR

IS TO CERTIFY THAT A PHYSICAL EXAMINATION WAS GIVEN TO:

___________________
DATE OF ISSUANCE

_____________________________________________________________
(Name of Personnel)

______________________
EXPIRATION DATE

THIS CERTIFICATE IS VALID FOR NOT MORE THAN ONE (1) YEAR.

(HE) (SHE) IS FOUND TO BE (FIT) FOR DUTY AS A: (SAME AS SECTION 7)

NAME AND DEGREE OF PHYSICAN____________________________________________________________________
(PLEASE PRINT)

ADDRESS ________________________________________________
NAME OF THE PRACTITIONER LICENSING AUTHORITY___________________________
SIGNATURE OF PRACTITIONER__________________________________________________________

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MEDICAL REQUIREMENTS
All AGOLL VENTURES LIMITED personnel to be engaged on the XYZ project shall be required to have a
physical examination reported on the Medical Fitness Certificate conducted by licensed physician. The Medical
Fitness Certificate shall accompany personnels certificates of competency and CV. This physical examination
shall be carried out not more than 6 months prior to the date of project commencement. Such proof of
examination shall establish that the personnel is in satisfactory physical condition for the specific duty
assignment undertaken and is generally in possession of all body facilities necessary in fulfilling the
requirements of the offshore operations. In addition, the following minimum requirements shall apply.
(a) All personnel must have hearing unimpaired for normal sounds and be capable of hearing a whispered
voice in better ear at 15 feet and in poorer ear at 5 feet.
(b) Offshore permitted personnel must have (either with or without glasses) at least 20/20 vision in one
eye and at least 20/40 in the other. If the personnel wears glasses, he must have vision without glasses
of at least 20/160 in both eyes. Offshore permitted personnel must have normal color perception and
be capable of distinguishing the colors red, green, blue and yellow.
(c) A personnels blood pressure must fall within an average range, taking age into account.
(d) Personnel afflicted with any of the following disease or conditions shall be disqualified: epilepsy,
insanity, senility, acute alcoholism, tuberculosis, acute venereal disease or neurosyphilis and/or the use
of narcotics.
(e) Personnel must have speech, which is unimpaired for normal voice communication.

IMPORTANT NOTE
The original or a stamped copy must be carried on board by the worker/personnel while serving on
AVLs/Clients work site in order to prove that he/she is medically fit.
DETAILS OF MEDICAL EXAMINATION
(To be completed by examining physician)
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