Form MED160 "Application Form for Aviation Medical Certificate" - United Kingdom

ADVERTISEMENT
ADVERTISEMENT

Download Form MED160 "Application Form for Aviation Medical Certificate" - United Kingdom

Download PDF

Fill PDF online

Rate (4.5 / 5) 12 votes
CIVIL AVIATION AUTHORITY
APPLICATION FORM FOR AVIATION MEDICAL CERTIFICATE
Complete this page fully and in block capitals – Refer to instructions for completion
MEDICAL IN CONFIDENCE
(3) Surname:
(4) Previous surname(s):
Title:
(13) UK CAA Reference number:
(5) Forenames:
(6) Date of birth:
(7) Sex
(12) Application
Initial
Revalidation
Renewal
(1) State of licence issue:
(2)
Medical certificate applied for:
1
2
(14) Type of licence applied for:
LAPL
3
(8) Place and country of birth:
(9) Nationality:
(15) Occupation (principal)
(10) Permanent address:
(11) Postal address (if different)
(16) Employer
(17) Last medical examination
Date:
Place:
(18) Aviation licence(s) held (type):
Tel:
Tel:
Licence number:
State of issue:
Email:
Email:
(500) GP Name:
(19) Any Limitations on
No
Yes
Licence(s)/Medical Certificate held
Address:
Details:
Telephone Number:
(20) Have you ever had an aviation medical certificate
No
Yes
denied, suspended or revoked by any licensing
authority? If yes, discuss with AME
Date:
Place:
Details:
(21) Flight time total:
(22) Flight time since last medical:
(23) Aircraft Class /Type(s)
presently flown:
N/A
N/A
N/A
(24) Any aviation accident or reported incident
No
Yes
(25) Type of flying intended:
N/A
since last medical examination?
Date:
Place:
N/A
Details:
(26) Present flying activity
Single pilot
Multi pilot
Current ATCO Activity
ADI
APS
ACS
(27) Alcohol – state average weekly intake in
units:
(29) Do you smoke tobacco?
Never
No
Yes
Date stopped:
State type, amount & number of years:
(28) Do you currently use any medication?
No
Yes
If YES, state medication, dose, date started and why
MED 160 04062018
Page 1 of 3
CAA Ref:
CIVIL AVIATION AUTHORITY
APPLICATION FORM FOR AVIATION MEDICAL CERTIFICATE
Complete this page fully and in block capitals – Refer to instructions for completion
MEDICAL IN CONFIDENCE
(3) Surname:
(4) Previous surname(s):
Title:
(13) UK CAA Reference number:
(5) Forenames:
(6) Date of birth:
(7) Sex
(12) Application
Initial
Revalidation
Renewal
(1) State of licence issue:
(2)
Medical certificate applied for:
1
2
(14) Type of licence applied for:
LAPL
3
(8) Place and country of birth:
(9) Nationality:
(15) Occupation (principal)
(10) Permanent address:
(11) Postal address (if different)
(16) Employer
(17) Last medical examination
Date:
Place:
(18) Aviation licence(s) held (type):
Tel:
Tel:
Licence number:
State of issue:
Email:
Email:
(500) GP Name:
(19) Any Limitations on
No
Yes
Licence(s)/Medical Certificate held
Address:
Details:
Telephone Number:
(20) Have you ever had an aviation medical certificate
No
Yes
denied, suspended or revoked by any licensing
authority? If yes, discuss with AME
Date:
Place:
Details:
(21) Flight time total:
(22) Flight time since last medical:
(23) Aircraft Class /Type(s)
presently flown:
N/A
N/A
N/A
(24) Any aviation accident or reported incident
No
Yes
(25) Type of flying intended:
N/A
since last medical examination?
Date:
Place:
N/A
Details:
(26) Present flying activity
Single pilot
Multi pilot
Current ATCO Activity
ADI
APS
ACS
(27) Alcohol – state average weekly intake in
units:
(29) Do you smoke tobacco?
Never
No
Yes
Date stopped:
State type, amount & number of years:
(28) Do you currently use any medication?
No
Yes
If YES, state medication, dose, date started and why
MED 160 04062018
Page 1 of 3
CAA Ref:
CIVIL AVIATION AUTHORITY
APPLICATION FORM FOR AVIATION MEDICAL CERTIFICATE
Complete this page fully and in block capitals – Refer to instructions for completion
MEDICAL IN CONFIDENCE
(3) Surname:
(4) Previous surname(s):
Title:
(13) UK CAA Reference number:
General and medical history: Do you have, or have you ever had, any of the following? YES or NO (or as indicated) must be ticked after each
question. Elaborate YES answers in the remarks section.
Yes
No
Yes
No
Yes
No
Yes
No
112 Nose, throat or speech
123 Malaria or other tropical
101 Eye trouble/eye
 
 
 
Females only:
disorder
disease
operation
113 Head injury or
150 Gynaecological, menstrual
102 Spectacles and/or
 
 
124 A positive HIV test
 
concussion
problems
contact lenses ever worn
114 Frequent or severe
125 Sexually transmitted
103 Spectacle/contact lens
151 Are you pregnant?
 
 
 
headaches
disease
prescriptions/change
since last medical exam
115 Dizziness or fainting
104 Hay fever, other allergy
 
 
126 Admission to hospital
 
Family history of:
spells
116 Unconsciousness for any
105 Asthma, lung disease
 
 
127 Any other illness or injury
 
170 Heart disease
reason
117 Neurological disorders;
128 Visit to medical
106 Heart or vascular trouble
171 High blood pressure
 
 
 
stroke, epilepsy, seizure,
practitioner since last
paralysis, etc
medical examination
118 Psychological/psychiatric
107 High or low blood
 
 
129 Sleep Apnoea
 
172 High cholesterol level
trouble of any sort
pressure
119 Alcohol/drug/substance
108 Kidney stone or blood in
 
 
130 Musculoskeletal illness
 
173 Epilepsy
abuse
urine
109 Diabetes, hormone
 
120 Attempted suicide
 
131 Refusal of Life insurance
 
174 Mental illness
disorder
121 Motion sickness
132 Refusal of Flying
110 Stomach, liver or
 
 
 
175 Diabetes
requiring medication
licence/ATCO licence
intestinal trouble
122 Anaemia/Sickle cell
133 Medical rejection from or
111 Deafness, ear disorder
 
 
 
176 Tuberculosis
trait/other blood
for military service
disorders
134 Award of pension or
177 Allergy/asthma/eczema
compensation for injury
or illness
178 Inherited disorders
179 Glaucoma
(30) Remarks: If previously reported and no change since, so state.
(31) Declaration: I hereby declare that I have carefully considered the statements made above and that to the best of my belief they are complete and correct and
that I have not withheld any relevant information or made any misleading statement. I understand, that if I have made any false or misleading statements in
connection with this application, or fail to release the supporting medical information, the Licensing Authority may refuse to grant me a medical certificate or may
withdraw any medical certificate granted, without prejudice to any other action applicable under national law.
I hereby authorise the release of all information contained in this report and any or all its attachments and all information which I have provided to the CAA and that
relates to me to my AME and, where necessary, to:
the medical assessor of my licensing authority; and
the medical assessor of the competent authority of my AME; and
other health professionals and administration staff
as part of the medical assessment process. I recognise that these documents or electronically stored data are to be used for completion of a medical assessment
and for oversight purposes, providing that I or my physician may have access to them according to national law. The medical record will become and remain the
property of the Licensing Authority. Medical confidentiality will be respected at all times.
NOTIFICATION OF DISCLOSURE OF PERSONAL DATA: I hereby declare that I have been informed and I understand that the data contained in my medical
certificate application according to ARA.MED.130 for Aircrew and ATCO.AR.F.005 for ATCOs may be electronically stored and made available to my AME in order
to provide historical data required in MED.A.035(b)(2)(ii)/(iii) and ATCO.MED.A.035(b)(2)(ii)(iii) and to the medical assessors of the competent authorities of the
Member States in order to facilitate the enforcement of ARA.MED.150 (c)(4) for Aircrew and ATCO.AR.F.001 for ATCOs.
-------------------------------------------------------
----------------------------------------------------
---------------------------------------------
Date
Signature of applicant
Signature of AME (Witness)
MED 160 04062018
Page 2 of 3
CAA Ref:
INSTRUCTION PAGE FOR COMPLETION OF THE APPLICATION FORM FOR A MEDICAL CERTIFICATE
This application form and all attached report forms will be transmitted to the licensing authority. Medical confidentiality shall be respected at all times.
The applicant should personally complete, in full, all questions (sections) on the application form. Writing should be legible and in block capitals, using a
ball- point pen. Completion of this form by typing/printing is also acceptable. If more space is required to answer any questions, a plain sheet of paper
should be used, bearing the applicant’s name and signature, and the date of signing.
The following numbered instructions apply to the numbered
headings on the application form for a medical certificate.
Failure to complete the application form in full, or write legibly, may result in non -acceptance of the application form.
The making of false or
misleading statements or withholding of relevant information in respect of this application may result in criminal prosecution, denial of this application
and/or withdrawal of any medical certificate(s) granted.
1. LICENSING AUTHORITY:
17. LAST APPLICATION FOR A MEDICAL CERTIFICATE:
State name of country this application is to be forwarded to.
State date (day, month, year) and place (town, country).
Initial applicants state ‘NONE’.
2. MEDICAL CERTIFICATE APPLIED FOR:
18. LICENCE(S) HELD (TYPE):
Tick appropriate box.
State type of licence(s) held. Enter licence
number and State of issue. If no licences are held, state ‘NONE’.
Class 1: Professional Pilot
Class 2: Private Pilot
500. GP NAME:
Class 3: ATCO
Completion of this area is optional
LAPL
3. SURNAME:
19. ANY LIMITATIONS ON THE LICENCE(S)/MEDICAL CERTIFICATE:
State Surname/Family name.
Tick appropriate box and give details of any limitations on your licence(s)/medical certificate e.g,
vision, colour vision, safety pilot, etc.
4. PREVIOUS SURNAME(S):
20. MEDICAL CERTIFICATE DENIAL, SUSPENSION OR REVOCATION:
Tick ‘YES’ box if you have ever had a medical certificate denied, suspended or revoked, even if
If your surname or family name has changed for any reason, state
previous name(s).
only temporary
If ‘YES’, state date (dd/mm/yyyy) and country where occurred.
5. FORENAME(S):
21. FLIGHT TIME TOTAL:
State first and middle names (maxi mum three).
State total number of hours flown.
6. DATE OF BIRTH:
22. FLIGHT TIME SINCE LAST MEDICAL:
Specify in order dd/mm/yyyy
State number of hours flown since your last medical examination.
7. SEX:
23. AIRCRAFT CLASS/TYPE (S) PRESENTLY FLOWN:
Tick as appropriate.
State name of principal aircraft flown e.g. Boeing 737, Cessna 150, etc.
8. PLACE AND COUNTRY OF BIRTH:
24. ANY AIRCRAFT ACCIDENT OR REPORTED INCIDENT SINCE LAST MEDICAL
State town and country of birth.
EXAMINATION:
If ‘YES’ box ticked, state Date (dd/mm/yyyy) and Country of
accident/Incident.
9. NATIONALITY:
25. TYPE OF FLYING INTENDED:
State name of country of citizenship.
State whether airline, charter, single -pilot, commercial air transport, carrying passengers,
agriculture, pleasure, etc.
10. PERMANENT ADDRESS:
26. PRESENT FLYING ACTIVITY:
State permanent postal address and country. Enter telephone area
Tick appropriate box to indicate whether you fly as the SOLE pilot or not.
code as well as telephone number.
11. POSTAL ADDRESS (IF DIFFERENT):
27. DO YOU DRINK ALCOHOL?:
If different from permanent address, state full current postal address
Tick applicable box. If yes, state weekly alcohol consumption eg, 2 litres of beer.
including telephone number and area code. If the same, enter ‘SAME’.
12. APPLICATION:
28. DO YOU CURRENTLY USE ANY MEDICATION?:
If ‘YES’, give full details - name, how much do you take and when, etc. Include any non-
Tick appropriate box.
prescription medication.
13. REFERENCE NUMBER:
29. DO YOU SMOKE TOBACCO?
State Reference Number allocated to you by the licensing authority
Tick applicable box. Current smokers state type (cigarettes, cigars, pipe) and amount (eg, 2
Initial applicants enter ‘NONE’.
cigars daily; pipe - 1 oz weekly)
14. TYPE OF LICENCE APPLIED FOR:
GENERAL AND MEDICAL HISTORY
All items under this heading from number 101 to 179 inclusive should have the answer ‘YES’ or
State type of licence applied for from the following list:
‘NO’ ticked.
Aeroplane Transport Pilot Licence
You should tick ‘YES’ if you have ever had the condition in your life and describe the condition and
Multi-pilot Licence
approximate date in the ( 30) remarks box.
Commercial Pilot Licence/Instrument Rating
All questions asked are medically important even though this may not be readily apparent.
Commercial Pilot Licence
Items numbered 170 to 179 relate to immediate family history, whereas items numbered 150 to
Private Pilot Licence/Instrument Rating
151 should be answered by female applicants only.
Private Pilot Licence
If information has been reported on a previous application form for a medical certificate and
Sailplane Pilot Licence
there has been no change in your condition, you may state ‘Previously Reported; No Change
Since’. However, you should still tick ‘YES’ to the condition.
Balloon Pilot Licence
Do not report occasional common illnesses such as colds.
Light Aircraft Pilot Licence
And whether Fixed W ing / Rotary W ing / Both
Other – Please specify
15. OCCUPATION:
Indicate your principal employment.
16. EMPLOYER:
31. DECLARATION AND CONSENT TO OBTAINING AND RELEASING INFORMATION:
If principal occupation is pilot, then state employer’s name or if self -
Do not sign or date these declarations until indicated to do so by the AME who will act as witness
employed, state ’self’.
and sign accordingly.
n
MED 160 04062018
Page 3 of 3
CAA Ref:
Page of 3