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MEDICAL EXAMINATION REPORT

IVICTJ NO 8663 5r'MCU IS__CI W,r LN }(, V Il I.i24

NANIE M R. LONGGIN T]S ]\'IELYANGAM
SEX ilIale
PLAC-E & DATE OF BIRTH : IiATIONALITY : INDONESIA
AIIBON, SEPTET{BER 04, 1989
IVIAIL1NG ADDRESS OF EXAMINEE:
JL. KAREL SATS{|TT ABUN -PASSO RT.{}O#AA2 KEL. PASSO KEC. EAGUALA KOTA
DUTY : CHIEFOTTICER PASSPOR-I : E 6084159
NIEDICAt, HISTOR}I PHISICAL
( EXAMTNEE PERSONAI, DECLARA:I'|ON )
Q
\ ry16[t u'
Yes i No HEIGHT WEIGET BI,OOD PIlI,S-IH RESPIRA"' TORY
1. ALCOHOL FIISTORY NO I'RESSI,IRIi REGULAR RATE
2. ALLERGIC HISTORY Ns 165 76 i 30180
3. AN,,{PUTATION NO cm kg mmHg 80 X/min 20X / min
4. BLOOD DISORDER No
5. BALANCEPROBLEM No \lSIOhI WITIIOLTT WIT}I COi,OR VISION
6. BACK OR JOINT PROBLEM No CLASSES (tsrIIAR{'S lr,rE-rrr()D)
7. COLOUR BLINDNESS Nq
8. CANCER No Right Eye 2A125
9. DIABETES Nq Left Eye ZAns NOR.IVIAL
DISORDER
10. DIGESTIVE No Both Eye 24t25
1 l. DEPRESION No
12. EP1LEPSY No CENERAL APPEARA.NCE
I3. EYE i VISION PROBLEN,{ NO
14. EARPROBLEM No LOOKINC TIEALTHY
IS.FRACTURE No
I6.GENITAL DISORDER No NORMAL
17. HEARTSURGERY No l. EYES Yes
18. HEARTDISEASE Ns 2. EARS Yes
]9. HIGH BT,OOD PRESSURE NO 3. NOSE Yes
20. HERNIA No 4. MOUTH Yes
2l.INFECTIOUS DISEASB No 5. THROAT Yes
22. KIDNEY PROBLEM No 6. NECK Yes
23. I,LING DISEASE NO 7. THRO1D Yes
24. LIVER PROBLEM No 8. LYMP NODE Yes
25. LOST ()F MEMORY No 9. L{rNGS Yes
26. NARCOTIC HISTORY Ns 10. HEARTS Yes
27. NEUR.0CICAL DISEASE Ntt I I. ABDOMEN Yes
2S.OPERATION I SURGERY No 12. UROGENITAI, SYSTEM Yes
29.PSYCHIATRIC PRBLEM No 13. UPPER EXTREMITIES Yes
3O.RESTRICTED MOBILITY NO 14. LOWER EXTREMITIES Yes
3l.SKIN PROBLEM No 15. BACK ABNORMALITY Yes
32.SLEEP PROBI-EIVI Na 16. HERNIA Yes
33.THYROID PROBLEM No 17" CENTRAL NER.VOUS SYSTEM Yes
34. TUBERCULOSIS No NAILS
18. SKIN & Yes
SPEECH
19. Yes
20. OTHERS Yes
DENTAL EXAMINATION HEARII{G If abnormal , give details
87654i211 ll34-i678 Normal
816543211 12315 67 8 Right Ear Yes NII,
o : Filling O Caries /' : Root Rest Leaft Ear Yes
r : Missing V Prothesa
\

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REPORT LABORATORY RESULT

Company : LEANEX CO. LTD

Name : MR. LONGGINfIS MEI,YANGAM No MR : 86635
1VICU No. : 8663 5/MC UIS_C W/LNX/V III/24 Sex : Male
Date Examination :AUCUST 31,2424 Age : 35 Years Old

Laboratory Test Result Reference Ranges

HAEMATOLOGY
Haemoglobin 14,2 r3.0- 16 grldl
White Blood Cell Count 9,1 5.0 -10 Thsn i ul
ESR 7 <10 mm / hour
Thrombocyte 255 I 50 440 /ul
Differential Count
Basifil 0 0- I %
Eosinofil
.}
I- 3 O/
/o
o/
N. Batang ) 1 6 )o
N. Segmen ,10 70 o/
/tt
6"7
Linrposit 23 20 4A o/
/tt
') oh
Monosit 5 6

SEROLOGY / IMMT]NOLOGY
HIV Non Reactive Non Reactive
VDRL Non Reactive Non Reactive

TIRINALYSIS
Macroscopic
Spesific Gravity 1B2g 1.000 - 1.0:10
Albumin Negative Negative
Glucose Negative Negative
PH 5
Microscopic
Sediment
Iipithels i hpf Positive Positive
WtsC / hpf 0-2 <- -)

RBC / hpf 0-3 <3

Cast Negative Negative
Clystal Negative Negative
Bacteria Negative
0thers Negative

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LABORATORY FINDTNG

BLOOD TEST URINALYSYS

HEMATOLOGY SPECIFIC GR,dFITY : 1020

PROTEIN : Negative
HB 14,2 gr/dl Gt,IICOSE : Negative
WBC 9,1 Thsn i ul PH :5
o/o
Differential Count 02/3167123/5
ESR 1 mm / hours
Thrombocyte 255 lul MTCROSCOPIC
BLOOD CHEMISTRY
WBS 0-2 I hpt
GDS mg/dl RBC 0-3 /hpt
SGOT Li/L CAST Negative
SGPT L]ilL CRYSTALS Negative
Creatinin mg/dl BACTERIA Negative

SEROLOGY / IMMUNOLOGY
HIV : Non Reactive
\T}RL : Non Reactive

CHEST X-RAY Report : NORMAL No.86635

OTHER DTAGNOSTIC TEST

ECG : NORMAL
COMMENT ON MEDICAL HISTORY AI{D CLINICAL EYALUATION
The abovenamed person physically :

gI FIT
N FIT WITH MINOR CORRECTABLE DEFECT
N HAS MAYOR PHYSICAI, DEFECT ; FIT WITH RESTRICTION OF SELtrCTED ASSIGNMENT
N UNFIT

Fcr duties on board ship FIT TO BE DUTY ON BOARD SHIP

Doctcr's Advice

HBALTH CERTTFICATB
No. : 86635iMCUlS_CW/LNXlVlll/2,1

THIS TO CERTTFICATE THAT A MEDICAL EXAMINATION WAS GTVEN TO

MR. LONGGINUS MELYANGAM AGE 35
HE IS FOUND TO BE FIT rOR DLTY AS : CI{IEF O}'FICER
ISSUED AT JAKARTA
DATE, AUGUST 31,2024
VALID UNTIL, AUCUST 31.2426

YAWATI

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CERTIFICATION
DRUGS AND ALCOHOL

MCU. No : 86635/MCUIS_CWLNX /lll/24

Company : LEANEX CO. LTD
Date : AUGUST 31,2024

This is to certify that

Name : MR. LONGGINUS MELYANGAM
Sex : Male
Place/Date Of Birth : AMBON, SEPTEMBER 04, {989
Age : 35 Years Old
Rank : CHIEF OFFICER

Was examed for the presence of the following drugs and alcohol in the urine using the
competitive immonoassay / chomatographic Absorbent method and was found :

1. Amphetamine Negative Coccaine Negative

2. Methamphetamine N/E Marij uana/Cannabinoids Negative
3. OpiatelMorphine Negative Barbiturate N/E
4. Phencyclidine Negative Benzodiazepine N/E
5. Codeine N/E Alcohol Negative

Note
N/E Not Examine

T 31, 2424

Revier.v Officer

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MC[J NO : 8663slMctils Cw/l.Nxivlll/24

DECLARATION OF ANTI HIV TEST RESULT

Name : MR. LONGGINUS MELYANGAM

Age : 35 Years Old

Adress : JI,. KAREL SATSUITUBLIN -PASSO RT.OO6/OO2 KEL. PASSO KEC. BAGUALA KOTA
AMRON

Company : LEANEX CO" LTD

Is : Non Reactive

This is to certify that the test is correct and true.

JAKARTA. ALiGUS'T 3 I ^ 2024

ISMAYAWATI
[)fficer

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CHESTX-RAYREPORT
( PA \TEw )

Company : LEANEX CO. LTD Date : AUGI"IST'31,2024

Name : MR. LONGGINI"iS MELYANGAM Age ; 35 Years Old
NICU No. : 86635IMCUIS CIViLNX/Vllllz4 Rad, No : 86635

THE LUNG FIELDS NO INFILTATES IN BOTII FIELD OF THE LUNG

THE. HILAR IS NORMAL
BRONCHOVASCULAR MARKING 15 NORMAL

THE CARDIAC NORI\{AL

THE AORTIC OUTLINES NORMAL

THE COSTOPHRENIC SINUSES ; NORMAL

DONTAS OF DIAPHRAGM NORMAL

SCLETAL ABNORMALITY NIL

OTHER ABNOR]VIALITY NIL.

CONCLUSION HEART AND LUNG NORMAL

,$A r

RADIOLOCIST

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MEDICAL FITNESS CERTIFICATE

Name: LONGC;INLl S IVIELYANGAM

Sex: I\4ale l)ate of Birtir: 041091 1989
Nationality: INDONESIA Passport No: E 60841 59
Occr"rpatior uJRank: C HIE F OF FICER
Date oflssue: AUGUST 31,2024
Date of Expiry:ALJGUST 31.2026
,d
Signature of Holder:

'Ihis is to certify that the lawful holder had been found cluly qr-ralilied in *
I

Labor
Convention -20A6 as amended, and STCW 1978 as amended regulation Cuidelines fbr
conducting pre-sea and periodic medical fitness examinations fbr seafbrers

Declaration of the recognized Medical Practitioner:

Confirrnation that identification docnnrents Fit for look out duties

were checked at the point of examination?
Yes / bie Yes / No

Hearing meets the standards in section A- Fit for service at sea

119 af STCW Code? Yes / Ne Yes i ).ie

Unaided heari ng satisfactory? Is the seat-arer free from any

Yes / Ne rnedical condition Iikely to be
aggravated by service at sea or
Visual acuity meets standards in section A- to render the seaf-arer unfit for
Yes /Ne
I/9 of STCW Code? such service or to endanger tlre
Yes / Ns irealth of other persons on
board?

Color Vision meets standards in section A- any limitations or restrictions

l/9 of STCW Code? on fitness? If Yes, Please
Yes / Nc specit-v
Yes /No

Date of last color vision test ,fr$ffi;;".,/}

AUGUST 31,,2024
Date
-u,Ag Signatr-rre & Stamp

Valiclity of certificate: 2 years from the date oiissue except fbr persons below 1B years on the date of medical
examination where this certificate is valid fbr I lear f'rom the date of issue.

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Clinical Findings
165 (cm)
Heighr: Weight:76 (kg)
Pulse rate: 80x l(minute) Rhlthm: 20 x /l\,{in.
Blood Pressure: Systolic: 130 (mm llg) Diastolic: 80 (mm Hg)

Visual acuity Ilearing

Normai Normal speech Otoscopy
ata (Tvmpanic
Ljnaided Aidecl distarce of4rn X4ernbrane)
Ri-eht Left Binocular Right Left Binocular Right v
e,ve eVLl Eve Eye I'ilr
Ilistant 616 6,6 616 I-eft ear V
Near 20125 2A125 20,25 Colour Vision
Visual fields Normal Defective
Normal Del-ective
Right eye
Left eye V
Normal Abnonrral Normal Abnormal
Head Varicosc vcins
v
Sinuses, nose- throal Vasoular (iac. pedal pulscs)
v
Mouthiteeth Abdomen and viscera
Vt v
Fiars ( general) FIemia
v v
Anus {not rectai exam)
Eyes
v
Ophthalmoscopv G-U system
Y v
Pupils Upper and lower ertremities
Eye movement Spine (C/S, T/S and US)
v
Lungs and chest Neurologic (tu1l/bneI)
v
Brea-st eramination Ps-vchiatric
v
Heart (ieneral appearance
v
Skin
v

Other diagnostics Tests and results

Test Result
Chest X-ray Normal
HIV Negative
VDRL Negative
Urinalysis: Clucose: Negativc Protein: Negative Blood: Ncgative
ECG(il required): Normal
On the basis ofthe eraminec's personal declaration. il1 clinical eramiuation anci ihe diagnostic test results recorcled above, I deciare
ihat thc crrnrince rnetlically:
Is applicant sufl'ering flom any rnedical condition likely to be aggravated by servicc at sca or to rcndcr the seaf'arer unfit lbr such service or to
endanger the healrh ofthe other persons on boarcl ? 1'es n No E

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E] Fit lor look-out duty fl N.:t f.it for look-out rluty

f)eck service Engine service Catering service Other service

Fit u n n n
{lnl-rt n n
:*ti+hRes+rie+iees
Without restrictions Visual aid Ye1+ No
Dcsclibc rcstrictklrs (e.g.. specilic position. t1,pe of ship" trixle area)

i\.{edical date of 3tl08/2a26

Date Medical certiflcate issued (day/month/year): _3 I 108 / 2024 _
Medical practitioner inibrnration (rame" license number^ addrr:ss ):
T B^XAS--VQ.& N-o.72 -
JA]'AJ{'IA U TAILA

ol lv{edical Practitioncr

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Pre-Emnloyment and Periodic Medical Fitness Certificate of Seafarers

Issued in accordance n'ilh lV{alitime l.abor L-otvention 2006a-s amended- and S l'CW 1978 as anrended regulation I/9 and
il,0/\\,llO Guidelines for condrrcting pre-sea and peiiodic rneclical fitness craminations tbr scal'arers-

N ame: (last"l'irst.miclclle) MELYANGAM. Date of birth 04 SEPTEMBER I989

(day/montb/year):
LONGGINUS
Gencler: (m al e/l'emtrle) Male Nationality: TNDONESIA
Ilome Address: JL. KAREL SATSUIT UBUN -PASSO RT.OO6/OO2 KEL. PASSO
KEC. BAGLJALA KOTA AMBON
Passport No. E 6084r59 Dlscharge book
No.:
Type of Ship: Trade Arear
(e.g. container, tanker,passenger,fishing) (coastal, tropical,
worldwide)

Department: (Deck- Enginc. DECK

Catering,Otherl

Conditio Yes No Condition Yes No

1. E-vclvision problcnr V 18. Slcep problcrn
2. Iligh blood pressure V 19. Do t,ou smoke. use alcohol or drugs? IIorv nruch pcr dar,..
3. Heart/vascular disease 20. OperationlSurgery V
Hezul 1l 21. v
5. Varicose veins/piles V 22. Di zz.i nesslihi nti n p \/
6. Asthrnaibronch:itis v 23- [,oss of consciousness \/
7. Ulood disorder 24. Psychialric problerns
8. Diabetes v 25. Depression V
9.Thvroid problenr v 26. Attempted suicide
10. Digestive disorder 27. Loss o1'memorv V
11" Kidney Problem V 2ll. Balance problem
12. Skin ploblern 29. Severe headaches V
li. Allgcrsies 30. Ear(hearing. tinnitus) /nose/throat problem v
14. lnl'ectious/contagious diseases 1/ 31. Restricted mobilitv
I 5.1 {errria v 32. Back or.ioint problerr V
l6.Genital disordcr 33. Anrputation 1/
17. Pregnancl' v 34. Fractures/dislocations v
If you ansrvered ";.,es" to any of the above questions, pleare give details:

Additional questions
Have ever AS ot' a
Have CYEI
37. Flave you eyer been declared untit lbr sea duiy'l v
38. Has vour nedical cerliflcate even been restricted or revoked? \/
39. Are vou aware that you have an-v tredical pr-erilems, diseases or illnesses? \/
40. Do vou feel healthv and fit to peribrtr the duties of 1'oLrr designated positionl occupation',)
41. Are you allereic to an_v ntetlicationl) \/
Comments:

42. Are you taking anv non-prescription or prescription nredications? v

If you answered "yes" to any of the above questions, please give details:

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rights to a revierv incase the result is unfit or fit rvith anl, limitations.

I hereby authorize the release ofall my previo$s medical records frorn any health professionals, health institutions and public authorities to Dr.
SAID HUSIN (the pproved medical practitioner),

Date 31 ,' 08 ;' 2024

Si gnature of e.xamiree:

Witnessed by: (Signarure) _

N*:ne:
FIT TO BE DUTY ON BOARD SHIP

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 MEDICAL EXAMINATION (SEAFARERS) CONVENTION 73
.147
UNDER ILO CONVENTION
MEDICAL REPORT FOR SEAFARERS
Name LONGGINUS Mtrl-YANGAN,l Sex: M
/ Companv LEANIX CO. I- fL)
Vessel Age: I'i Occupation CI{]EI OFFiCER

1 Have you ever been lreated ior any YES NO History:

disease. njury or operat:or................ n M
Z Are you taking any medication now...... n ;-,
u
J Are yor presenrly Jrwel1........... u U
4 Have you ever been rejected to' History:
employment on rnedical 9rounds.................. n M
q Have ycu ever been repalriated
{or medical reasons................ n rn

I declare that all answers are to the best o{ my knowledge and bellel lrue. I am lully aware that it i withhold any information, this pre employment
examination will be considered null and void.
I hereby grant permission to the examining physician to disclose any and all in{ormation herein or herea{ter {urnished by me to the Company as
as may be deemed necessary.

ALTGLjSI' 31.2024
Patient's signature Witness Date

GENEFAL CONDITION
NORMAL ABNORMAL
16
Height lO5 metre
.
Weighl kg Liver w n
Visr,ral acuity lell 6r t) right 6,1 6 -uiib.€iffies n
without Elasses Kidneys ry n
Colour vision red S Blue w green I I\,{asses
Auditory acuity Lett E/ right Q
Tympanic l"4embrane lntacl E HerToIaIeo L_-.1

Bellex M n
CARDIOVASCULAR SYSTEM l,4uscular tone M n
regular [l Babinski M n
Pulse 80 ,/min rhythm ........20........ irregutar E M I
Blood pressure systolic
l 30/80 mirrmurs
diastolc
& tr
RESPIRATORY SYSTEM NOHMAL ABNOBMAL & n
Deformity M tr
Percussion N
N g?.!i.Y'
Chesl expansion -v An arysis Sr:sar. I9.e. fli.ufru, *in 9

Airscultaiion j

lnvestigations Positive Neoatjve

Chest Xray U oorur tl ruor ooNr n N
NO EVIDENCE OF ACTIVE LUNG PATHOLOGY n N
MUSCULOSKELETAL SYSTEM. NORMAL ABNOBMAL lest(s) if applicabie:
It4uscu{ar power M D
Deformity

CONCLUSION:
Commenls :

From the medical ical examination. I am ol the opinion that the above seaman is medically FIT lor duties at sea.
UNFIT-

A.UCUST 31, 2024

Date
The validity of this years.
\
Jt-iHEPP,{t/09

GOVERNMENT OF MALAYSIA
ir4arire depalinent Malaysia. Ibu Pejabat Laut Semoarjung \'lalaysia Psti Surat 12,120A1 Pelabuhan
Klarg Tel: 03-3686616. Fax: 0ll-3685289. Esail; kdgrr'ri\urine.qol'.m] htfp:ri11\rrv.rnar;ne.go1 .rr\

MEDICAL EXAMINATION CERTIFICATE

LONGCINUS i,{HLYANGAM
Narne of holcier of Ce.rtiflcale

r_ 0(,d+ r f',
Seanran Card I'lumber identity Card Number

I certify that I have examined the above-named seafarer to standards of the medical and
eyesight of lVlalaysia as rn the lVlerchant Shipping (l\ledical Examination) Rules 1999, and
have found him fit for seafaring subject to the foilowing restrictions.

NIL

Category of Medical Fitness: A

Date of examination ,!1,(;t,sT 31" 202.r

Date of expiry of this Cerlificate A1'Ct S I 3l-2026

DT, SAID HUSIN

p Signature of approved medical practitioner

Registration MMC: IpL/HEpp.257t Jtd il

MMC Registration: This certificate is issued by ty'te Govemmenl of Malaysia
in coupliance with the rctluirements of Article 2(a)(iii) of the convention concerning minimum standards in
Mercltant Ships Conyention 1976(ILO No. l47) under Regulation accepted {rs equi?ale?rl lo Medicol Examinslion
{Seafarers) Convenlion }946 (7Vo. 73)
 JLI}IEPPID/16

'lE S IiVION lAl - 0F S UA N.!AN I I i-,- 1) F RGOI NG \,1E DIC AL EXAM INAI'ION

I)lease ansrver lhe folio*ing uith letbrence lo I'our ireairh. Tick X in the appropriate '\'es' or 'No' ooiumn. il- ticked
'l'cs' please elaborate in lhe remarks colulnn.

l)o 1-ou have any history or are undergoing treatrnent in an'" o1'thc iirlouing:

No Regarding \es No Remarks

I Eye disorders
- llataract
-Monocular sight
-Other tactors rvhich hir-rdcr r'ision
2 Colour blird
-l Night hlindness
4 Conr,ulsion or fits
5 Hcav-,- injurics to head
6 Dizziness
'l Severe headachc or migraine

I \'1aiol hrain ofrcratior

I Diahetis r.rndergoing insulin treatment
l0 N{ental Disorder
II lVlisuse of alcohol/dnigs rvithin lasl 5 ycars
12 Spinal dislbrmiLl,
l3 ilead disease/ hlperlension/ hearl. palpi lal.itxs
t4 tlrcathing dil'liculty/ biood vonritting/ clronic cough
i5 Dealiress
llr Kidnev disease
17 An1' rcgular mcdical trcatrnsnt
l8 r\nv iniuryidiseas. not statecl alrove

I declare lhat the in{bl'nration given above is coffeot to tlie best ofm1'knolvledge. I lirl1her declare that J have not hidden
anr, infbmation or made lalse statement q,hicb can jcopardizc nr1, rvork. I do give pcmrission for the medical
practitioner to corumunicate rvith an,r other medical practitioners or the Marine Departnlent in an)'miltters u,hich can
a{lLct my placcmcnt on board a vessel.

App Iic ont:; si gtrtfi o' e Seonrun Curd No.

Nnile (i]t copitol lrrrrlo.I GG I rr- U SM E[.YANGAI\,{ I NRlrc/futssport Nnifibel

E 6084159
tl^rl lr
Witnessed b-t' (Dr) Dr. -'\
oC.rpitionit

()fficiul Stanryt of lfecliccl Pracritioner

\
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.h
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JABATAN I-AUT MAI-AYSIA
lbu Pejabat Inut SflamjugMalaysia, Peti Su* 12, ,12007 Pelabaha KImg TeI: 03-369510O, Fu: 03-3685289,
E-mil : kogr@mine. gov.my htto://ww.rmine. gov.my

MED]CAL PRACTITIONER'S REPORT

I have eranri,,erl I-ONGGINUS MELYANGAN4 ICIPassport No: E 60841 59

as per the Malaysian Marire Department rnedical standards JL,?/02/98 and the results are as follows:

HeightNeight 165 *"t *.

'76 v. F]XAMINATION

Heariag 4d"g1ut" 4d"qyt*

.iCht left FlT
2A/25 2*/2s
Eyesight
dCht left
Eyesight with visuai aids F SHIP
dght le11

TE]!{PORARILY UNFIT
Colour Vision NORMAL

Urinalysis Negartivi gula Negative albrunin

Puise 80 /mnt
Blood pressure I ll.t;(5t,

Chest X-ray
Nornral/,Abnorn+ai X-ral n"riunrber.

ECC NormaiiAhx*tral

Normal Abnomrall Remarks

f . infectious diseases

2. Malignant Neoplasm MT
a
J.
C^A^--i^^
LIIUULIIIIE -^.J nr^+^h^l:-
dIIU IVICIdUUIIL
n:..^-.^
UIJCdJC r-:;

4. Disease of the blood and

kl^^,.l
UIUVV {^.*i^
{vl lll'i lEi UrECllJ

5. Mental Disorders M il
5. Central Nervous system E I
7. Cardiovascularsystem t,;l

6.
o n^-,^i--!^
i{esprraiory sysrem

9. Digestive system

10. 6enito-Urinary System MI

11. Pregnancy No Yes (week

12, JNI r L.VJ tl

\
 13. Musculo-skeletal system il
14. Speech Defects M t_l

15. Ears/Nose/Throat t_v.l n

10. trye5 I

SAID HUS]N
AI.TGUST 31,2026
Tiris certilicatc is valid until

-\ir n:r ur',:,r1 \leJical Pr-act it icrrcr

MlvlC No:
Date
A{JGUST 31,2024

DT. SAID HUSIN, MD

REGISTER MALAYSIA
No. lDN041 (INDONESIA)
 KERAJAAN MALAYSIA
GOVERNME]{T OF MALAYSIA
Marine Headquafiers, Malaysia Marine Department, P.O Box 12,42007 Port Klang
Tel: 03 - 3346 7777, Fax: 03 - 3168 5289, E-mail: [email protected] , Website: http://www.marine.gov.my

SIJ IL PEMERIKSAAN PERU BATAN

ME D I CAL EXAMINATI O lY C E RTI F I CATE
Name Given
1) Nama pemegang sr;il (seperti dalam passport):
Name oJ'holder oJ Certi;ficctte (cts in passport):

I ) *Jantina: Lclaki \Nynita 3) Warganegara: 4) No. Kad Pelaut:

Gt'ttd. r" llulc F{ntlt Itrafionalie: i1r{aN€sA Seafarer Card No,

5) 6)
No. Kad Pengenalar.r/Passport:
I den ti ty Card lV o/P a s sport : e Ur$\ tst Tarikh Lahir (dd/mm/yyyy):
Date of Birth: d{

7) Jawatan:
P roJbssion: tKWf tlffitC0L
8) Pengakuan oleh Pengamal Perubatan yang Diiktiraf:
Declaration of the Recognized Medical Practitioner:
Yes/Ya No/Tidak
8.1 Pengesahan dokumen pengenalan telah disemak ketika pemeriksaan:
Confirmation that identffication documents were checked at the point of examination: ,/
8.2 Pendengaran menepati piawaian mengikut seksyenA-I/9 Konvensyen STCW 78 seperti dipinda
Hearing meets the standards in section A-I/9 of the STCW 78 as amended

8.3 Pendengaran memuaskan tanpa apa-apa bantuan?

LIn aide d hearing s atis fa ct ory ? v
8.4 Ketajaman penglihatan menepati piawaian mengikut seksyen A-i/9 Konvensyen STCW 78 seperti dipinda?
Visual acuiQ meets standctrds in section AJ/9 of the STCW 78 as amended?

8.5 Penglihatan wama menepalipiawaian mengikut seksyen A-I/9 Konvensyen STCW 78 seperti dipinda?
Colour yision meets standctrds in section A-119 o.f the STCW 78 as amended?
- Tarikh terakhir ujian penglihatan wama:
Dote of la<t , ulottr vision t,.:.t: 11 (oB

8.6 l-ayak untuk tugas peninjauan?

Fit Jbr l ook-out duti es ?

8.7 Tiada had atau sekatan dari aspek kecergasan'7

l{o Limitations or restriction on;t'itness? v
Jika "Tidak", nyatakan had dan sekatan:
If "lVo", spectfu linti.tation or restrictions;

8.8 Adakah pelaut bebas dari apa-apa keadaan perubatan yang mungkin dimudharatkan melalui perkhidmatan
laut atat boleh menyebabkan seseorang pelaut tidak layak untuk perkhidmatan sedemikian atau mungkin
membahayakan kesihatan mana-mana orang di atas kapal?
Is the seafarer free from any medical condition likely to be aggravated by service at sea or to render the
seafarer unfitfor such sertice or to endanger the other person on board? v
 No:JLM 4661-06

Saya mengesahkan bahawa saya telah memeriksa pelaut seperli di atas mengikut standard perubatan dan penglihatan Malaysia
I certifv that I have exantined
the above-named seafarer to slandards of the medical a.nd eye,sight o/'Malaysia
sepertimana dalam Kaedah-Kaedah Perkapalan Saudagar (Pemeriksaan Perubatan) 1999 seperti pindaan,
as i.n the Merchanl Shipping (Medical Exarnination) Rules 1999 as amended,
dan didapati beliau *layak atau tidak layak untuk menjalankan tugas pelaut dengan pembatasan-pembatasan berikut:
and hcrve fottnd him to be *fit or unfit.fttr seafaring subiect to the.fbllov,ing restrictions:

FilT]mBEOWOffiMfiIffi$ffiilP

9) Kategori Kecergasan Perubatan

Category of Medical Fitness: A

10) Tarikhpemeriksaan (dd/mm/yy1y): 1i) Tarikh luprit sijil (dd/mm/yyyy)

Date of Examination: $ foTl ?rtq Expin' clate of certificate: 1\ ldl u4
12) Tandatangan pelaut:
Signat ure of s ea"/arer :

13) Nama Pengamal perubatan: dr. SAID HUS|N.

Name of medical practitioner. 1 12.102131 72.A4 fi051 1.71 9 3et?fi17

14) Tandatangan pegamalperubatan:

Signattu'e of m edicaI pra cti tioner : u

l5) Pendaftaran MMC: DT. SAID HUSIN, MD 16) Cop rasmi: * B

MMC Rcgi.str',triotr: Oficial Stamp:

REGISTER MALAYSIA
No. lDN041 (INDONESIA) a trf0
- This certficate is issued by the Government of Malaysia in compliance with the requirements of Title I .Regulation I .2 under Maritime Labotr
Convention (2006)

- The maximum yalidity of this certificate is only two (2) years

*strikethrough whichever not upplicable