Medical Fitness For Duty

Fitness for duty determinations require that medical practitioners understand the underlying physical condition, how that condition is impacted by service in the maritime environment, and how the condition itself can impact maritime and public safety. This involves not only knowing the mariner, but understanding the conditions in which he or she works and possibly lives.

• Seafarers work in a multitude of environments and conditions that can impact their physical condition and may prevent them from obtaining timely medical care. Remote locations with minimal, if any, medical resources can be common and the loss of a functioning mariner on a vessel can significantly impact the rest of the crew, both in regards to routine and emergency duties.

• Medical conditions need to be considered in respect to their existing functional impairments, stability, need for surveillance, and risk of incapacitation.

• Medical practitioners should consider medication needs, possible impairment or incapacitation from medications, and consequences to the seafarer for missed dosages or lost medications.

• Physical ability requirements are discussed in Enclosure (2) of the NVIC 04-08 and must be considered in relation to the seafarer’s medical condition. It should be understood that mariners must be able to perform both routine and emergency procedures.

• Medical conditions that preclude performance of these duties increase risk to the remaining crew, to property, and to public safety.

• Recommendations for fitness for duty by treating practitioners will be taken into consideration by Coast Guard personnel performing evaluations. It should be noted, however, that treating practitioners often make recommendations without fully understanding fitness for duty guidelines and Marine Transportation System (MTS) safety needs. Final determinations will be made in accordance with the overriding safety needs of the MTS.

The determination of whether or not a mariner is fit for full duty is based on a medical evaluation of the physical examination and supporting documents submitted by the applicant. The medical evaluation is a three step process, however, not all applicants are subject to all three steps:

1) Medical Screening: We have entry level medical professionals that review every single physical that arrives in the medical division. They have limited ability to grant waivers, but are still able to move over 70 percent of the daily files that will not require further review.

2) Initial Medical Review: Any medical condition that has been deemed outside of the capability of the screening staff is reviewed by a medical evaluator. These medical evaluators review the physicals that require a more comprehensive review (medications, injuries, illness, significant medical histories, etc.). The medical evaluators have the ability to grant waivers, request amplifying information when not enough documentation has been provided, and are authorized to speak with an applicant's physician when there are questions with regards to fitness for duty requirements or requested information. Nearly 90 percent of initial medical reviews will result in waivers that will not require further scrutiny.

3) 2nd Level Review: When a physical examination has been evaluated and the medical evaluator has determined that the mariner may not be fit for duty, the file is submitted to our senior evaluation staff for final determination. Less that 2 percent of all physicals sent for 2nd level review will be found not fit for duty.

The medical screening process is an administrative review of the CG-719K or CG-719K/E Merchant Mariner Credential Medical Evaluation Reports submitted to the NMC Medical Evaluation Division (NMC6). Medical screeners review the 719K and determine if an applicant’s file requires a medical evaluation, an operational limitation, a hearing waiver, or a vision waiver.

The Medical Screeners’ ability to grant waivers and credential limitations is pursuant to guidance found in NMC work instructions and the Medical Division Chief’s instruction. This process allows for up to 70% of applications processed through the NMC Medical Evaluation Division (NMC6) to move on to the next credentialing step without additional medical review.

The medical evaluation process is an administrative review of Merchant Mariner Examination Report (CG 719K), submitted to the NMC Medical Evaluation Division (NMC6) after unsuccessful screening due to any medical history, any listed medications, or any missing/erroneous information on the Merchant Mariner Examination Report.

Mariners applying for entry level positions (Ordinary Seaman, Wiper, or Food Handler) are not held to the same medical standards as mariners applying for qualified rating positions, such as First Class Pilot (FCP), Master, Able Seaman, and Chief Engineer. If an FCP is suddenly incapacitated while performing duties, the risk to maritime safety is much greater than if an Ordinary Seaman is incapacitated. Guidance for conducting fitness for duty evaluations for merchant mariners is derived from 46 CFR Parts 10 & 12, NVIC 04-08, and the medical judgment of the Medical Evaluations staff.

Medical waivers are granted for conditions documented on Merchant Mariner Medical Examination reports when the condition has been identified as not posing a significant risk to maritime safety. The waiver is an acknowledgement by the NMC that the condition was identified and places a responsibility on the mariner to report any significant change in this identified condition. Conditions that have progressively worsened may potentially affect a mariner’s fitness for duty determination.

When granting a waiver, the Coast Guard may apply a requirement or limitation to the waiver. It is the mariner’s responsibility to read the waiver letter and any applicable requirements/limitations in order to maintain the waiver. Again, 46 CFR does not specifically address the innumerable diagnoses with possible associated requirements. NVIC 04-08, however, does state that one of the outcomes of the NMC medical review may be that “the applicant does not possess the vision, hearing, or general physical condition necessary, but a credential may be issued with appropriate limitations, waivers and/or other conditions for issuance of the credential as specified by the NMC.”

Mariners are required to sign, date, and return a copy of their waiver letter to NMC (as instructed). The mariner should carry this waiver letter at all times while acting under the authority of the credential.

Waivers may be rendered invalid due to changes in a mariner’s medical condition or if a mariner fails to comply with waiver submission requirements.

Frequently, a mariner’s medical examination report will indicate treatment for an illness, injury, or prescription for a medication that requires further documentation in order to make a fitness for duty determination. Amplifying Information (AI) refers to information requested by the medical evaluation staff to complete a medical evaluation. Of the physicals submitted to the NMC, 90 percent are lacking the information required to make fitness for duty determination, resulting in requests for AI.

When completing the CG 719K or K/E application, please ensure that all blocks are filled on examination forms. Forms with missing information will incur delays in processing.

Section III Medications: Verify that ALL medications, vitamins, dietary supplements, and/or performance enhancing substances are listed with dosages and frequency. This includes both prescription and non-prescription substances.

Section IV Certification of Medical Conditions: Review and verify the medical history as reported by the mariner. Provide details of conditions as indicated on the form and aid the mariner in submitting the supporting medical documentation needed for the conditions. The requirements for this supporting documentation are listed in the NVIC 04-08.

• Failure to provide supporting medical documentation for conditions can lead to significant delays in processing and evaluations.

Section V (a) Visual Acuity: Ensure that both corrected AND uncorrected visual acuity are recorded, if applicable.

Section V (b) Color Vision: Non-standardized tests are not acceptable at this time. This includes yarn tests, crayons, pointing out primary colors in your office, etc. Please contact the NMC for any questions regarding the tests listed or to determine if an alternative test is acceptable prior to submitting form.

Section VI Hearing: Instructions are as follows:

Per CFR § 10.215:   Hearing Requirements

(c) Hearing test. If the medical practitioner conducting the general medical exam has concerns that an applicant's ability to hear may impact maritime safety, the examining medical practitioner, if not qualified to conduct the appropriate examinations, must refer the applicant to an audiologist or other hearing specialist to conduct an audiometer test and/or a speech discrimination test, as appropriate.

(1) The audiometer test should include testing at the following thresholds: 500 Hz; 1,000 Hz; 2,000 Hz; and 3,000 Hz. The frequency responses for each ear should be averaged to determine the measure of an applicant's hearing ability. Applicants must demonstrate an unaided threshold of 20 decibels or less in each ear.

(2) The Functional Speech Discrimination (FSD) test should be carried out at a level of 55 decibels. For issuance of an original MMC or endorsement, the applicant must demonstrate functional speech discrimination of at least 90%. For renewal or raise of grade, the applicant must demonstrate functional speech discrimination of at least 80%. An applicant who is unable to meet the standards of the audiometer test, but who can pass the functional speech discrimination test, may be eligible for a medical waiver in accordance with paragraph (g) of this section.

• Documentation of abnormal hearing on page 5 or page 6 of the 719K will require submission of an evaluation meeting the above mentioned testing guidelines. If audiogram results demonstrate an average threshold value of 30dB or lower for each ear, the Functional Speech Discrimination testing will not be required.

Section VII Physical Examination: Please ensure that all boxes are completed, including calculated Body Mass Index (BMI). Please use the Comments Section to describe any abnormalities found on physical examination or to elucidate the applicant’s medical history/conditions from Section IV.

Section VIII Demonstration of Physical Ability:

• If the examining medical practitioner doubts the applicant’s ability to meet the guidelines contained within this table and for all applicants with a Body Mass Index (BMI) of 40.0 or higher, the practitioner should require that the applicant demonstrate the ability to meet the guidelines. A description of the methods utilized by the medical practitioner should be reported on the CG-719K or CG-719K/E (or approved equivalent form) as appropriate.

• All demonstrations of ability should be performed by the applicant without assistance.

• Any prosthesis normally worn by the applicant and other aid devices such as prescription glasses may be used by the applicant in all practical demonstrations except when the use of such would prevent the proper wearing of mandated Personal Protective Equipment (PPE).

• If an applicant is unable to meet any of the guidelines contained within this table, the examining medical practitioner should provide information on the degree or severity of the applicant’s inability to meet the guidelines.

There are medical conditions that can delay an application for credentials or cause the application to be denied. If you have one of these conditions please take a copy of the recommended evaluation guidelines to your doctor so they may address the issue.

Please visit our Top 10 Medical Conditions website for further information.

According to 46 CFR 10.215 (g), “Where an application does not possess the vision, hearing or general physical condition necessary, the US Coast Guard, after consultation with the examining licensed physician, licensed physician assistant, or licensed nurse practitioner may grant a waiver, if extenuating circumstances warrant special consideration.” During the medical evaluation process, NMC may request amplifying information in order to obtain the necessary medical documentation to grant a waiver. Even though regulations do not specifically list medical diagnoses, condition, medications, etc. which may be granted a waiver, 46 CFR 10.215 (g) does indicate “general physical condition”, therefore a waiver may be applied.

When granting a waiver, the Coast Guard may apply a requirement or limitation to the waiver. It is the mariner’s responsibility to read the waiver letter and any applicable requirements/limitations in order to maintain the waiver. Again, 46 CFR does not specifically address the innumerable diagnoses with possible associated requirements. NVIC 04-08, however, does state that one of the outcomes of NMC medical review may be that “the applicant does not possess the vision, hearing, or general physical condition necessary, but a credential may be issued with appropriate limitations, waivers and/or other conditions for issuance of the credential as specified by the NMC.”

Mariners are required to sign, date, and return a copy of their waiver letter to NMC (as instructed). The mariner should carry this waiver letter at all times while acting under the authority of the credential.

Waivers may be rendered invalid due to changes in a mariner’s medical condition or if a mariner fails to comply with waiver submission requirements.

If your application has been denied for medical reasons, there are two options for you to consider.

First, In accordance with 46 CFR 1.03-40, you may request reconsideration of this decision. Your request for reconsideration should address any possible errors, provide new facts, information, and/or extenuating circumstances in order to mitigate the decision. The request for reconsideration must be made in writing and postmarked no later than 30 days after the date of the original letter. Your request for reconsideration will be reviewed, and you will then be notified that the NMC has either: (1) reversed/modified the initial decision, or, (2) upheld the decision to deny your application. If you disagree with the reconsideration decision, then you may make a formal appeal to the Director of Prevention Policy (CG54) at Coast Guard Headquarters, within 30 days of the date of the reconsideration letter.

While a request for reconsideration is pending, the original decision or action remains in effect, unless otherwise stated. Failure to submit a formal request for reconsideration in accordance with these procedures and time limits will result in the decision or action becoming final agency action. It is recommended that you retain copies of all material you send with any request for reconsideration. Please attach a copy of the letter you received to any documentation you provide us with in response to this notification.

Second, apply for a Document of Continuity by submitting a separate application via a CG Regional Examination Center and return your credential with the application in accordance with 46 CDR 10.227 (e). Documents of Continuity do not expire and are issued solely to maintain an individual’s eligibility to renew once qualified.

A team of qualified physicians reviews all reconsideration requests to determine if your eligibility has changed.

Reconsideration Approvals: Reconsideration approvals will be forwarded to Professional Qualifications Evaluations (PQE) for processing of your credential. A medical waiver may be included with your credential. (See Medical Waivers)

Reconsideration Denials: Your reconsideration package has been reviewed by our physicians who have determined that your eligibility is unchanged. The National Maritime Center (NMC) takes every step to ensure that reconsiderations are thoroughly reviewed. If we deny your reconsideration, your reconsideration denial letter is forwarded to the NMC Commanding Officer for final review and signature.

If your reconsideration request has been denied, there are two options for you to consider:

1. Formal Appeal: First, in accordance with 46 CFR 1.03-40, you may request a formal appeal. Your formal appeal should address any possible errors, provide new facts or information, and/or provide extenuating circumstances in order to mitigate the decision. The formal appeal must be made in writing and postmarked no later than 30 days after the date of this letter. Please send the formal appeal to the NMC. The NMC will then forward your appeal and your complete NMC file to Director of Prevention Policy (CG54) at Coast Guard Headquarters for consideration of your appeal.

While a formal appeal is pending, the original decision or action and reconsideration decisions remain in effect, unless otherwise stated. Failure to submit a formal appeal in accordance with the aforementioned procedures and time limits will result in the original decision or action becoming final agency action.

2. Document of Continuity:Your second option is to apply for a Document of Continuity. To apply for a Document of Continuity, you need to submit a separate application via a Regional Examination Center and return your credential with the application as per 46CFR 10.227(e). There is a 1-year grace period to renew once the MMC expires. If more time is needed, you also have the option to place your credential in a continuity status. For more information on a Document of Continuity, go to the NMC website.

Requests for a formal appeal following a reconsideration denial must be made in writing to the NMC. The NMC shall forward all appeal requests to the Director of Prevention Policy (CG54) at Coast Guard Headquarters. The Director of Prevention Policy (CG54) oversees all aspects of the appeal process. For information regarding the status of your appeal, please contact Director of Prevention Policy (CG54) at Coast Guard Headquarters.