Mariners holding only entry-level or staff officer endorsements can use this five-page short form when they want to serve as food handlers or need an STCW or MLC medical certificate without standing navigational or engineering watches. The practitioner records identity, food handler status, physical information and a demonstration of physical ability, then recommends certification to the National Maritime Center.
The mariner completes Sections I and VI and any optional consents in Section VII. A physician, PA or NP licensed by a U.S. state, possession or territory completes Sections II to V and initials and dates each page.
Download the current version from the source each time; forms change without notice.
Application for Medical Certificate, Short Form
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Mariners applying for or holding only entry-level or staff officer endorsements who want to serve as food handlers, or who need an STCW or MLC compliant certificate and will not stand navigational or engineering watches. No lookout duties are authorized, and every other applicant must use the full CG-719K medical exam.
A physician, physician assistant or nurse practitioner licensed by a U.S. state, possession or territory, who performs, witnesses or reviews all exams and demonstrations. The practitioner checks one current government-issued photo ID, completes the food handler, physical information and physical ability sections, and signs the Section V summary under 18 USC 1001.
Recommended, Not Recommended or Needs Further Review. For an STCW or MLC certificate, the practitioner also states whether the mariner is free from any condition likely to be aggravated by service at sea, to make them unfit for it, or to endanger others on board, and discusses any concerns.