Form

ML5 medical report form and certificate (MSF 4112)

A report for your medical history and current health; lets your doctor decide on your fitness to work safely at sea.

This publication was withdrawn on

MSF 4112 has been replaced by MSF 4112 rev 0508

Documents

Seafarer medical report form ML5 and ML5 certificate (MSF 4112)

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Details

Download and print these forms, and take them to your doctor to be filled in. It doesn’t have to be a Maritime and Coastguard Agency (MCA) approved doctor).

This form is for:

  • anyone applying for, revalidating, or changing their MCA Boatmaster’s Licence or certificate
  • anyone applying for a Royal Yacht Association (RYA) commercial endorsement for working on code vessels (see the form for more detail)
  • crew on a seagoing or domestic passenger vessel
Published 17 April 2014
Last updated 28 September 2016 + show all updates
  1. September 2016 Revision Uploaded
  2. First published.