A merican Club Circular No. 08/ 19 1 MARCH 15, 2019 CIRCULAR NO. 08/19 TO MEMBERS OF THE ASSOCIATION Dear Member: PRE-EMPLOYMENT MEDICAL EXAMINATION (PEME) PROGRAM: CHANGE TO THE EXAMINATION FORM CONCERNING PSYCHOLOGY TESTS Members are advised that, with immediate effect, the American Club will no longer require that psychology tests be performed for compliance with its PEME program. This change has been incorporated in the Club’s 2019 PEME form and 2019 Guidelines (Fourth Edition), as attached. Furthermore, your Managers have requested all clinics to update their PEME price list given this change. A new price list will be posted in due course. Yours faithfully, Joseph E.M. Hughes, Chairman & CEO Shipowners Claims Bureau, Inc., Managers for THE AMERICAN CLUB AMERICAN CLUB PRE-EMPLOYMENT MEDICAL EXAMINATION FORM—2019 IMPORTANT: The original of this form is to be kept by the seafarer. A copy must be kept by the clinic. Date of Examination: ________/________/_________ (dd/mm/yyyy) Seafarer’s Signature NOTE: The passing or failure of the medical examinations for the following is based upon the 2019 American Club Pre-Employment Medical Examination Guidelines. All relevant examinations must be completed and recorded below. Examination Results of Examination Examination Results of Examination Pass Fail Pass Fail 1. Medical History Questionnaire (attached) ☐ ☐ 13. Ultrasound examination (presence of gall and/or kidney stones) ☐ ☐ 2. Physical Examination ☐ ☐ 14. Hep B Antigen ☐ ☐ 3. Dental Examination ☐ ☐ 15. Hep C Antibodies ☐ ☐ 4. Psychological Test ☐ ☐ 16. VDRL ☐ ☐ 5. Visual Test ☐ ☐ 17. HIV Test ☐ ☐ 6. Color Vision ☐ ☐ 18. Stress Test ☐ ☐ 7. Audiometry ☐ ☐ 19. Diabetes ☐ ☐ 8. Chest X-ray ☐ ☐ 20. Fasting Blood Sugar ☐ ☐ 9. Electro Cardiogram (ECG or EKG) ☐ ☐ 21. Glycosylated Haemoglobin (HbA1c) ☐ ☐ 10. Urinalysis ☐ ☐ 22. Liver Function Test ☐ ☐ 11. Fecalysis (food service/handlers only) ☐ ☐ 23. Alcohol/Drug Test ☐ ☐ 12. Complete Blood Count ☐ ☐ 24. Spirometry ☐ ☐ If failed in any of the abovementioned examinations, please provide an explanation for the failure with the associated examination number: Exam #____ Exam #____ Exam #____ Has medication been prescribed because of this PEME? YES ☐ NO ☐ If “YES”, the American Club PEME Declaration Form MUST BE completed (third page). Name of Medical Clinic: Signature of Physician Address of Medical Clinic: Contact Phone No.: Contact Fax No.: Name and Degree of Physician: Name of Physician’s Licensing Body: Date of Issue of Physician’s License: Date of Completed PEME Examination: Expiry Date for PEME: (cannot be less than one calendar year) Name: Last Name First Name Middle Name Mailing Address: Date of Birth (dd/mm/yyyy) Blood Type/Group Place of Birth (City/Country) Name of Ship/Vessel Medical Certificate No.: Seafarer’s Certificate No.: PHOTOGRAPH American Club Hologram to be placed here AMERICAN CLUB MEDICAL HISTORY QUESTIONNAIRE—2019 IMPORTANT: This medical history form must be completed in the presence of the clinic physician. American Club Hologram Sticker No. (from previous page):__________ Doctor’s Initials: __________ Seafarer’s Signature If “YES” to any of the above, please explain: ___________________________ ___________________________________________________________________ ___________________________________________________________________ Any other major medical or physical conditions?_______________________ ___________________________________________________________________ ___________