Article ANNEXE 15 DE L'ARTICLE A. 4231-4-1
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Certificat médical d'aptitude en navigation intérieure
|||CONDITIONS D'APTITUDE PHYSIQUE ET MENTALE
I.-Modèle du certificat médical
Certificat médical relatif au contrôle de l'aptitude médicale en navigation intérieure
| Nom de naissance (nom d'usage s'il y a lieu) et prénom de la personne examinée| |
|-------------------------------------------------------------------------------|------------------------------|
| Date et lieu de naissance | Numéro de la pièce d'identité|
| Nom et prénom du médecin examinateur| |
|-------------------------------------|----------------------------|
| Adresse | Numéro (s) de téléphone (s)|
La personne examinée a fait l'objet d'un contrôle de son aptitude physique et psychique conformément aux standards pour l'aptitude médicale de l'ES-QIN (aptitude générale, vision et ouïe). Résultats du contrôle :
□ Durablement inapte
□ Temporairement inapte, probablement jusqu'au
□ Apte sans restrictions
□ Aptitude limitée jusqu'au (1)
□ Apte avec une ou plusieurs des restrictions suivantes (code de diagnostic conforme à l'ES-QIN)
□ 01 Correction de la vue (lunettes et/ ou lentilles de contact) requise
□ 02 Aide auditive requise
□ 03 Prothèse de membre requise
□ 04 Aucune tâche à accomplir seul dans la timonerie
□ 05 Uniquement lorsqu'il fait jour
□ 06 Aucune tâche navigationnelle autorisée
□ 07 Limitation au bâtiment suivant :
□ 08 Limitation au secteur suivant :
□ 09 Limitation à la tâche suivante :
Tampon
Date :
Lieu :
Signature du médecin :
(1) A n'utiliser que si cela est expressément prévu par les standards ES-QIN pour l'aptitude médicale relatifs à la maladie concernée.| |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------|
| Nom de naissance (nom d'usage s'il y a lieu) et prénom de la personne examinée | |
| Date et lieu de naissance | Numéro de la pièce d'identité|
| Nom et prénom du médecin examinateur | |
| Adresse | Numéro (s) de téléphone (s) || |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------|
| CONDITIONS D'APTITUDE PHYSIQUE ET MENTALE
I.-Modèle du certificat médical
Certificat médical relatif au contrôle de l'aptitude médicale en navigation intérieure
| Nom de naissance (nom d'usage s'il y a lieu) et prénom de la personne examinée| |
|-------------------------------------------------------------------------------|------------------------------|
| Date et lieu de naissance | Numéro de la pièce d'identité|
| Nom et prénom du médecin examinateur| |
|-------------------------------------|----------------------------|
| Adresse | Numéro (s) de téléphone (s)|
La personne examinée a fait l'objet d'un contrôle de son aptitude physique et psychique conformément aux standards pour l'aptitude médicale de l'ES-QIN (aptitude générale, vision et ouïe). Résultats du contrôle :
□ Durablement inapte
□ Temporairement inapte, probablement jusqu'au
□ Apte sans restrictions
□ Aptitude limitée jusqu'au (1)
□ Apte avec une ou plusieurs des restrictions suivantes (code de diagnostic conforme à l'ES-QIN)
□ 01 Correction de la vue (lunettes et/ ou lentilles de contact) requise
□ 02 Aide auditive requise
□ 03 Prothèse de membre requise
□ 04 Aucune tâche à accomplir seul dans la timonerie
□ 05 Uniquement lorsqu'il fait jour
□ 06 Aucune tâche navigationnelle autorisée
□ 07 Limitation au bâtiment suivant :
□ 08 Limitation au secteur suivant :
□ 09 Limitation à la tâche suivante :
Tampon
Date :
Lieu :
Signature du médecin :
(1) A n'utiliser que si cela est expressément prévu par les standards ES-QIN pour l'aptitude médicale relatifs à la maladie concernée. | |
| Nom de naissance (nom d'usage s'il y a lieu) et prénom de la personne examinée | |
| Date et lieu de naissance | Numéro de la pièce d'identité|
| Nom et prénom du médecin examinateur | |
| Adresse | Numéro (s) de téléphone (s) ||| |Arbre|Contenu| |
|-----|-------|---| | | |
|-------------------------------------------------------------|-------|---|
| Arbre |Contenu| |
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|---||
|---------------|
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|---| | | |
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|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------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-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---|
| |CONDITIONS D'APTITUDE PHYSIQUE ET MENTALE
I.-Modèle du certificat médical
Certificat médical relatif au contrôle de l'aptitude médicale en navigation intérieure
| Nom de naissance (nom d'usage s'il y a lieu) et prénom de la personne examinée| |
|-------------------------------------------------------------------------------|------------------------------|
| Date et lieu de naissance | Numéro de la pièce d'identité|
| Nom et prénom du médecin examinateur| |
|-------------------------------------|----------------------------|
| Adresse | Numéro (s) de téléphone (s)|
La personne examinée a fait l'objet d'un contrôle de son aptitude physique et psychique conformément aux standards pour l'aptitude médicale de l'ES-QIN (aptitude générale, vision et ouïe). Résultats du contrôle :
□ Durablement inapte
□ Temporairement inapte, probablement jusqu'au
□ Apte sans restrictions
□ Aptitude limitée jusqu'au (1)
□ Apte avec une ou plusieurs des restrictions suivantes (code de diagnostic conforme à l'ES-QIN)
□ 01 Correction de la vue (lunettes et/ ou lentilles de contact) requise
□ 02 Aide auditive requise
□ 03 Prothèse de membre requise
□ 04 Aucune tâche à accomplir seul dans la timonerie
□ 05 Uniquement lorsqu'il fait jour
□ 06 Aucune tâche navigationnelle autorisée
□ 07 Limitation au bâtiment suivant :
□ 08 Limitation au secteur suivant :
□ 09 Limitation à la tâche suivante :
Tampon
Date :
Lieu :
Signature du médecin :
(1) A n'utiliser que si cela est expressément prévu par les standards ES-QIN pour l'aptitude médicale relatifs à la maladie concernée.| |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------|
| Nom de naissance (nom d'usage s'il y a lieu) et prénom de la personne examinée | |
| Date et lieu de naissance | Numéro de la pièce d'identité|
| Nom et prénom du médecin examinateur | |
| Adresse | Numéro (s) de téléphone (s) | | | |
| CONDITIONS D'APTITUDE PHYSIQUE ET MENTALE
I.-Modèle du certificat médical
Certificat médical relatif au contrôle de l'aptitude médicale en navigation intérieure
| Nom de naissance (nom d'usage s'il y a lieu) et prénom de la personne examinée| |
|-------------------------------------------------------------------------------|------------------------------|
| Date et lieu de naissance | Numéro de la pièce d'identité|
| Nom et prénom du médecin examinateur| |
|-------------------------------------|----------------------------|
| Adresse | Numéro (s) de téléphone (s)|
La personne examinée a fait l'objet d'un contrôle de son aptitude physique et psychique conformément aux standards pour l'aptitude médicale de l'ES-QIN (aptitude générale, vision et ouïe). Résultats du contrôle :
□ Durablement inapte
□ Temporairement inapte, probablement jusqu'au
□ Apte sans restrictions
□ Aptitude limitée jusqu'au (1)
□ Apte avec une ou plusieurs des restrictions suivantes (code de diagnostic conforme à l'ES-QIN)
□ 01 Correction de la vue (lunettes et/ ou lentilles de contact) requise
□ 02 Aide auditive requise
□ 03 Prothèse de membre requise
□ 04 Aucune tâche à accomplir seul dans la timonerie
□ 05 Uniquement lorsqu'il fait jour
□ 06 Aucune tâche navigationnelle autorisée
□ 07 Limitation au bâtiment suivant :
□ 08 Limitation au secteur suivant :
□ 09 Limitation à la tâche suivante :
Tampon
Date :
Lieu :
Signature du médecin :
(1) A n'utiliser que si cela est expressément prévu par les standards ES-QIN pour l'aptitude médicale relatifs à la maladie concernée. | | |
| Nom de naissance (nom d'usage s'il y a lieu) et prénom de la personne examinée | | |
| Date et lieu de naissance | Numéro de la pièce d'identité | |
| Nom et prénom du médecin examinateur | | |
| Adresse | Numéro (s) de téléphone (s) | |
| |Arbre|Contenu| |
|-----|-------|---| | | |
| Arbre | Contenu | |
| || |
|---||
|---------------|
| | | | |
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|---| | | |
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