Manual of Standards for Licensing/Rating of ATC Personnel

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CIVIL AVIATION AUTHORITY OF NEPALL I C E N S I N G A N D RATING D I V I S I O NMEDICAL EXAMINATION FORM FOR ATCFull Name :... Date of Birth: -Type of Licence : Initial / Renewal( PHISYCAL & MENTAL EXAMINATION )Height : Weight : BMI :Indentifying body marks, scars, tatoos etc.Head, face, neck and scalpLungs and chest (including breasts)Heart (thrust size, rhythm, sounds)Vascular systemAbdomen and viscera (including hernia)Anus and rectum (hemorrhoids, fistula, prostate)Endocrine systemGenito - urinary systemUpper & lower extremities ( strength, range ofmotion, spine other musculoskeletal )Skin and lymphatiesNeurologic (tendon reflexes, equilibrium, sense, coordination)Psychiatric (specify any personality deviation)Blood pressure : Seated :... ............ Recumbent : ...Pulse : Seated :...Normal Describe abnormality in detail, use additionalYes No sheet if necessary & attach to this form( LABORATORY EXAMINATIONS )Urinalysis : Sugar : Albumen :Blood analysis : Hb : Sedimentation rate :ECG : Normal [ ] Abnormal [ ]Chest X-ray : Normal [ ] Abnormal [ ]Remarks if any :Applicant is/is not medically fit for ... ....................... . licencePlace of examination ... ................................................ Date... ..................................... . Aero-Medical Examiner's Signature
CIVIL AVIATION AUTHORITY OF NEPALL I C E N S I N G A N D RATING D I V I S I O NMEDICAL EXAMINATION FORM FOR ATCFull Name:.-.. Date of Birth: -Type of Licence: Initial / Renewal(EAR , NOSE & THROAT EXAMINATION & HEARING)Normal Describe abnormality in detail, use additionalYes No sheet if necessary & attach to this formNoseSinusesMouth and ThroatEars, general (int. & ext. canals)DrumsHearing Whispered Voice Conversational VoiceRight ear m ft 2m 6ftLeft ear m ft 2m 6ftAudiometry 500 1000 2000 3000Right ear dB loss [ ] [ ] [ ] [ ]Left ear dB loss [ ] [ ] [ ] [ ]Remarks, if any :Applicant is/is not medically fit for ... ....................... . licencePlace of examination ... ................................................ .Date... ..................................... . Aero-Medical Examiner's SignatureEyes, general, visual fieldsOphthalmoscopicPupils (equality and reaction)Ocular motilitynystagmus )( EYE EXAMINAITON, VISION & COLOR PERCEPTION)Normal Describe abnormality in detail, use additionalYes No sheet if necessary & attach to this form(associated parallel movement,Distant vision : Uncorrected CorrectedRight eye 6/ 6/Left eye 6/ 6/Both eye 6/ 6/Near vision :30 - 50 cm. ( 12- 20 in. ): N-chart value: 5Intermediate vision :100 cm. (40 in.) N-chart value:Color Vision : Normal ( ) Abnormal ( )Prescription for correcting lenses (when required) :Remarks if any :Applicant is/is not medically fit for ... ....................... . licencePlace of examination ... ................................................ .Date... ..................................... . Aero-Medical Examiner's Signature
Page 1 and 2: Manual of Standards forLicensing/ R
Page 3 and 4: FOREWORDThe Air Navigation Services
Page 5 and 6: MOS-Licensing/ Rating of ATC Person
Page 19 and 20: APPENDIX - AThe detail of theory ex
Page 21 and 22: COORDINATION AIRSPACE KNOWLEDGE TRA
Page 23 and 24: APPENDIX - CICAO LANGUAGE PROFICIEN
Page 25: CIVIL AVIATION AUTHORITY OF NEPALAP
Page 29 and 30: CIVIL AVIATION AUTHORITY OF NEPALME

Manual of Standards for Licensing/Rating of ATC Personnel

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