USCG CG-719K 2009 free printable template

Reported on a prior CG-719K but only for those CG-719Ks submitted after December 31 2008 and only for those conditions which have not changed since the condition was previously reported on a prior CG-719K. 2100 2nd Street SW. Washington DC 20593-0001. Applicant Name Previous Edition Obsolete Date of Birth Reset Page 2 of 9 of CG-719K Rev. 01-09 General Instructions for Medical Practitioner 1. U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-719K Rev. 01-09 Merchant Mariner Credential...

How to fill out USCG CG-719K

How to fill out USCG CG-719K

1. Obtain a copy of the USCG CG-719K form, which is available online or at a local Coast Guard facility.
2. Read the instructions carefully to understand the requirements for completing the form.
3. Fill out your personal information in Section 1, including your name, address, and contact details.
4. In Section 2, provide information about your physical condition and any medical history that may affect your ability to operate a vessel.
5. Answer all questions honestly and provide detailed descriptions where necessary.
6. Review your responses to ensure accuracy and completeness before signing the form.
7. Submit the completed form to your local Coast Guard office along with any required documents or fees.

Who needs USCG CG-719K?

1. Any individual seeking to obtain a Merchant Mariner Credential (MMC) from the US Coast Guard.
2. Those who have a medical history or condition that may impact their ability to operate a vessel safely.
3. Mariners who need to demonstrate their physical and mental fitness for maritime duties.

Instructions and Help about USCG CG-719K

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...

People Also Ask about

Does a merchant mariner credential work as a passport?

6. Can I use my MMC as a Passport? No. While the MMC is a government-issued document, when traveling abroad you are still required to possess a valid U.S. Passport.

How long is a CG-719K good for?

This means the certificate is really only good for 18 months. For those of you required by your company to get an annual physical, make sure the medical provider fills out the Coast Guard medical form (CG-719K), and make sure to submit it annually.

What is CG-719K or CG-719K E?

The CG-719 K/E form should be used only by mariners seeking an entry level merchant mariner credential. This form is limited to applicants for the following rating endorsements: Ordinary Seaman, Wiper, or Steward's Department (food handler). The CG-719K form should be used for all other endorsement applications.

How long is a CG 719K good for?

This means the certificate is really only good for 18 months. For those of you required by your company to get an annual physical, make sure the medical provider fills out the Coast Guard medical form (CG-719K), and make sure to submit it annually.

What is CG-719K?

APPLICATION FOR MEDICAL CERTIFICATE (FORM CG-719K)

How do I submit a USCG medical form?

The preferred method to submit your application and supporting documentation is via e-mail to MEDAIP@uscg.mil. Please include your full name in the subject line and ensure attachments are in PDF format. A CG-719B can ONLY be submitted to a Regional Exam Center.

What is CG 719K or CG 719K E?

The CG-719K and CG-719K/E serve as applications for a medical certificate. In order to renew the medical certificate prior to expiration, mariners must submit an application. Applications can be submitted through a Regional Exam Center (REC) or directly to the NMC.

How long does it take to get Coast Guard medical certificate?

NPT is the total time the Coast Guard spends processing the application and does not include the time waiting for information from mariners. The NMC has set a NPT goal of 20 days.

How long is a merchant mariner credential good for?

An MMC is valid for a term of 5 years. Adding an endorsement during this period does not change the expiration date. The only time the expiration date will change is when a mariner applies for and meets all renewal requirements. Once an MMC has expired, a mariner may not serve under the authority of that credential.

How do I submit an application for Merchant Mariner credential?

Steps to Apply for an Original MMC Determine the Officer and/or Ratings that you wish to obtain by visiting the NMC's Checklist Page. Obtain a Transportation Worker's Identification Credential. Fill out a CG-719B Application for Merchant Mariner Credential. (IF APPLICABLE) Fill out a CG-719C Conviction Statement.

How long does it take to get a USCG medical certificate?

NPT is the total time the Coast Guard spends processing the application and does not include the time waiting for information from mariners. The NMC has set a NPT goal of 20 days.

How to submit form cg-719K?

For a medical certificate only, the preferred way to submit your CG-719K or CG-719K/E (medical certificate applications) along with any supplemental medical information is via e-mail to MEDAIP@uscg.mil. Please include your full name in the subject line.

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What is USCG CG-719K?

USCG CG-719K is a medical examination form used by the United States Coast Guard to assess the physical and mental fitness of individuals applying for certain licenses and merchant mariner credentials.

Who is required to file USCG CG-719K?

Individuals applying for a merchant mariner's credential (MMC), including those seeking to operate certain vessels or engage in specific maritime activities, are required to file USCG CG-719K.

How to fill out USCG CG-719K?

To fill out USCG CG-719K, individuals must complete the form with accurate personal information, medical history, and any relevant health conditions, followed by a medical professional's certification.

What is the purpose of USCG CG-719K?

The purpose of USCG CG-719K is to ensure that individuals seeking to operate vessels are medically fit and able to safely perform their duties on the water.

What information must be reported on USCG CG-719K?

USCG CG-719K requires reporting personal identification details, medical history, current medications, and answers to specific health-related questions that may impact maritime safety.