AMC2 ATCO.AR.D.003(a)(2) Change of competent authority

• ED Decision 2023/011/R found in: Air Traffic Controllers Licensing and Certification (2015/340) Part-ATCO (Jun 2024)

AMC2 ATCO.AR.D.003(a)(2) Change of competent authority ED Decision 2023/011/R SUMMARY OF MEDICAL HISTORY — FORM FOR THE TRANSFER OF ATCO MEDICAL RECORDS <table border="1" cellpadding="0" cellspacing="0" width="623"> <tr> <td colspan="4" valign="top" width="623"> <p align="center"><b>SUMMARY OF MEDICAL HISTORY — FORM FOR THE TRANSFER OF ATCO MEDICAL RECORDS</b></p> <p align="center">MEDICAL CONFIDENTIALITY SHALL BE ENSURED AT ALL TIMES AS PER POINT <a href="#_DxCrossRefBm1379192624">ATCO.MED.A.015</a></p> <table border="1" cellpadding="0" cellspacing="0"> <tr> <td valign="top"> </td> </tr> </table> </td> </tr> <tr> <td valign="top" width="62"> <p>Item</p> </td> <td valign="top" width="250"> <p>Description </p> </td> <td colspan="2" valign="top" width="312"> </td> </tr> <tr> <td valign="top" width="62"> <p>1</p> </td> <td valign="top" width="250"> <p>State of licence(s) issue </p> </td> <td colspan="2" valign="top" width="312"> <p><i>Country</i></p> </td> </tr> <tr> <td valign="top" width="62"> <p>2</p> </td> <td valign="top" width="250"> <p>Title of licence and corresponding serial number of the licence(s) held <br/> (or national medical reference number)</p> </td> <td colspan="2" valign="top" width="312"> <p><i>UN country code ATCO.xxx</i></p> </td> </tr> <tr> <td valign="top" width="62"> <p>3</p> </td> <td valign="top" width="250"> <p>Full name </p> <p>(Last and first names)</p> </td> <td colspan="2" valign="top" width="312"> <p><i>LAST NAME 1, LAST NAME 2, etc. </i></p> <p><i>First name 1, First name 2, etc.</i></p> </td> </tr> <tr> <td valign="top" width="62"> <p>4</p> </td> <td valign="top" width="250"> <p>Date of birth (dd/mm/yyyy)</p> </td> <td colspan="2" valign="top" width="312"> <p><i>dd/mm/yyyy</i></p> </td> </tr> <tr> <td valign="top" width="62"> <p>5</p> </td> <td valign="top" width="250"> <p>Address </p> </td> <td colspan="2" valign="top" width="312"> </td> </tr> <tr> <td valign="top" width="62"> <p>6</p> </td> <td valign="top" width="250"> <p>Contact details:</p> <p>(a) email:</p> <p>(b) phone number:</p> </td> <td colspan="2" valign="top" width="312"> <p><i>e.g.</i></p> <p><i>(a) example@example.eu </i></p> <p><i>(b) +(country code) xxxxxxxxxx</i></p> </td> </tr> <tr> <td valign="top" width="62"> <p>7</p> </td> <td valign="top" width="250"> <p>Nationality </p> </td> <td colspan="2" valign="top" width="312"> <p><i>Country</i></p> </td> </tr> <tr> <td valign="top" width="62"> <p>8</p> </td> <td valign="top" width="250"> <p>Transferring authority</p> </td> <td colspan="2" valign="top" width="312"> <p><i>Country and authority</i></p> </td> </tr> <tr> <td rowspan="3" valign="top" width="62"> <p>9</p> </td> <td rowspan="3" valign="top" width="250"> <p>Initial medical certificate or the first medical certificate available in the competent authority:</p> </td> <td valign="top" width="151"> <p>Date of issue</p> </td> <td valign="top" width="161"> <p><i>dd/mm/yyyy</i></p> </td> </tr> <tr> <td valign="top" width="151"> <p>Date of examination</p> </td> <td valign="top" width="161"> <p><i>dd/mm/yyyy</i></p> </td> </tr> <tr> <td valign="top" width="151"> <p>Type (European Class 3, Part ATCO.MED, or national)</p> </td> <td valign="top" width="161"> </td> </tr> <tr> <td rowspan="3" valign="top" width="62"> <p>10</p> </td> <td rowspan="3" valign="top" width="250"> <p>Dates of last three</p> <p>revalidation/renewal examinations (if any)</p> </td> <td colspan="2" valign="top" width="312"> </td> </tr> <tr> <td colspan="2" valign="top" width="312"> </td> </tr> <tr> <td colspan="2" valign="top" width="312"> </td> </tr> <tr> <td valign="top" width="62"> <p>11</p> </td> <td valign="top" width="250"> <p>Limitations (if any)</p> </td> <td colspan="2" valign="top" width="312"> </td> </tr> <tr> <td valign="top" width="62"> <p>12</p> </td> <td valign="top" width="250"> <p>Comments on any relevant aspect of the applicant’s medical history or examination (if appropriate, please enclose reports). </p> <p>Enclose as minimum the examinations and investigation results as required by AMC1 <a href="#_DxCrossRefBm1379192366">ATCO.AR.D.003</a> <i>Change of competent authority</i>, point (a).</p> </td> <td colspan="2" valign="top" width="312"> </td> </tr> <tr> <td valign="top" width="62"> <p>13</p> </td> <td valign="top" width="250"> <p>Past or pending enforcement action*</p> </td> <td colspan="2" valign="top" width="312"> <p>Yes o                                    No o</p> <p>(If yes, please provide details on a separate page.)</p> </td> </tr> </table> If there is insufficient space on this form for further information, please use an additional page. <table border="1" cellpadding="0" cellspacing="0" width="623"> <tr> <td colspan="3" width="623"> <p><b>Certification</b></p> </td> </tr> <tr> <td colspan="3" width="623"> <p>I, Dr ……………………………, medical assessor of the (competent authority name)………………………., certify that the details given above and on any additional pages included are true and correct.</p> </td> </tr> <tr> <td valign="top" width="198"> <p>Date </p> </td> <td valign="top" width="202"> <p>Signature </p> </td> <td rowspan="2" valign="top" width="224"> <p>Transferring authority and stamp/seal</p> </td> </tr> <tr> <td width="198"> </td> <td valign="top" width="202"> </td> </tr> </table> \* *Item 13*: Specify whether there is a current investigation into the medical certificate and licence, or its suspension or revocation. *[applicable from 4 August 2024 - ED Decision 2023/011/R]*