Free 416-056-000 physical exam requiree for charter boat operators license - Washington

Department of Labor and Industries WISHA Services Division PO Box 44655 Olympia WA 98504-4655 Physical examination of

PHYSICAL EXAMINATION
REQUIRED BY THE DEPARTMENT OF LABOR AND INDUSTRIES

for State of Washington Charter Boat Operators License

(TO BE COMPLETED BY PHYSICIAN)
Height Weight Color Eyes Color Hair

EYES:

Color Sense is

is NOT

Normal.

Color perception checked by one of the following acceptable methods: (check one)
Farnsworth Lantern Keystone Orthoscope Keystone Telebinocular SAMCTT (School of Aviation Medicine Color Threshold Tester) Titmus Optical Vision Tester Farnsworth Dichotomous D-15 Panel Test

Pseudoisochomatic Plate (Dvorine, 2nd Edition;

ADC; revised edition or ADC-HRR Isherara 16-, 24-, or 38- plate editions). VISION:
Without glasses: With glasses: Right eye: Right eye Normal: Right ear: Right ear: Left eye Left eye Discharge: (feet) (feet) Left ear: Left ear: (feet) (feet)

EARS:

Auditory canals: Ordinary conversation: Loud Conversation

GENERAL:

Heart:

Blood Pressure:

Lungs:

Major defects, abnormalities, communicable diseases:

PHYSICIAN'S STATEMENT OF FINDINGS
I have on this date: examined: who has signed below in my presence. Upon evaluation of the above finding, I consider the applicant Competent
Printed name of physician Address of physician Date exam submitted for file City State license number of physician

Not competent

to perform the duties for which he/she is applying.
Phone number State ZIP+4

Signature of applicant: Physician's signature:

F416-056-000 physical exam -charter boat 7-05