USCG CG-719K 2017-2024 free printable template

Video instructions and help with filling out and completing cg 719k

Instructions and Help about uscg physical form

Welcome to the National Maritime centers instructional video on completing the US Coast Guard seven one nine series of applications form CG seven one nine K is the application for merchant mariner medical certificate the first three pages provide detailed instructions on filling out the form the table on page two provides details of the requirements for a demonstration of physical ability each section listed in the instruction corresponds with a specific section of the form also throughout the form there are instructions following each section heading which indicate whether the applicant or the medical practitioner should complete each section please read these instructions carefully prior to filling out the application in section 1 please fill in each block with appropriate contact information or write n/an if not applicable for section 2a you will need to mark all boxes with the appropriate yes or no response both of these sections should be reviewed by your medical practitioner also please remember to fill in the applicant name and date of birth blocks at the bottom of each page of the form section 2b should be completed by a medical practitioner for any conditions marked yes in section 2a the practitioner should list the corresponding number of the condition from section 2a and list the condition and diagnosis date of onset or date of diagnosis any treatment required or received the current status of the condition and any limitations you may have due to the condition as applicable your medical practitioner may attach supporting documentation please make sure any additional sheets include your name and date of birth for section 3 please list all prescription medications prescribed filled refilled or taken within 3 thirty days prior to the date you sign this form also list any non-prescription over-the-counter medications including dietary supplements or vitamins used for a period of 30 or more days within 90 days of the date you sign this form if you have not taken medications during this time frame please check the box marked none this information must be reviewed by your medical practitioner all medications listed must include dosage as well as the condition for which the medication is taken you may attach additional sheets if necessary please make sure any additional sheets include your name and date of birth section 4 is for information on vision and should be completed by the medical practitioner the practitioner must indicate tests used and results use of color sensing lenses is prohibited every test and demonstration for the medical examination must be performed witnessed or reviewed by a physician nurse practitioner or a certified physician assistant these practitioners must be licensed by a US state possession or territory the same practitioner who performs the examination must also review sections 2 camp; 3 of this form in section 5 the medical practitioner should indicate whether hearing is normal abnormal or if a hearing aid is...