[Federal Register Volume 84, Number 174 (Monday, September 9, 2019)]
[Rules and Regulations]
[Pages 47141-47146]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-19370]



Coast Guard

46 CFR Part 10

[Docket No. USCG-2018-0041]

COMDTINST M16721.48 Merchant Mariner Medical Manual

AGENCY: Coast Guard, DHS.

ACTION: Notification of availability.


SUMMARY: The Coast Guard announces the availability of the Merchant 
Mariner Medical Manual, Commandant Instruction Manual (COMDTINST 
M16721.48). The guidance in this Manual should assist medical 
practitioners, the maritime industry, individual mariners, and Coast 
Guard personnel in evaluating a mariner applicant's physical and 
medical status to meet the requirements of the merchant mariner medical 
certificate. This Manual incorporates and consolidates prior guidance 
on the medical evaluation of merchant mariners contained in several 
Coast Guard documents. The Manual includes guidance on the medical 
certificate and related processes, including procedures for 
application, issuance, and cancellation of the medical certificate.

DATES: The Merchant Mariner Medical Manual, COMDTINST M16721.4, is 
effective on September 9, 2019.

FOR FURTHER INFORMATION CONTACT: For information about this document or 
to suggest changes, call or email Adrienne Buggs, M.D., United States 
Coast Guard, Office of Merchant Mariner

[[Page 47142]]

Credentialing; telephone: 202-372-2357, email: [email protected].


Viewing Documents

    The Merchant Mariner Medical Manual, COMDTINST M16721.4, is 
available on the internet at: https://www.dcms.uscg.mil/Our-Organization/Assistant-Commandant-for-C4IT-CG-6/The-Office-of-Information-Management-CG-61/About-CG-Directives-System/ and on 
CGPortal at: https://cgportal2.uscg.mil/library/directives/SitePages/Home.aspx. A link to the document will also be located on the National 
Maritime Center (NMC) site: https://www.dco.uscg.mil/Our-Organization/Assistant-Commandant-for-Prevention-Policy-CG-5P/National-Maritime-Center/.

Background and Discussion of the Merchant Mariner Medical Manual

    Coast Guard regulations contained in 46 CFR part 10, subpart C, 
provide the medical and physical standards that merchant mariner 
applicants must meet prior to being issued a merchant mariner medical 
certificate. The Merchant Mariner Medical Manual provides guidance to 
the regulated community on how to comply with the regulations 
pertaining to medical and physical qualifications for merchant 
    Previously, the Coast Guard provided guidance on the medical and 
physical requirements for merchant mariners in the Medical and Physical 
Evaluation Guidelines for Merchant Mariner Credentials, Navigation and 
Inspection Circular (NVIC) 04-08, Commandant Publication (COMDTPUB) 
16700.4; in the Guidance on the Issuance of Medical Certificates (NVIC 
01-14); and in Part A of the Marine Safety Manual, Volume III, Marine 
Industry Personnel, COMDTINST M16000.8 (Series) [MSM]. The Merchant 
Mariner Medical Manual revises, updates and combines the medical 
evaluation guidance previously published in NVIC 04-08, Part A of the 
MSM, Volume III, and NVIC 01-14. The Coast Guard developed the draft 
Manual in consultation with experienced maritime community medical 
practitioners and industry stakeholders serving on the Merchant Mariner 
Medical Advisory Committee (MEDMAC) and the Merchant Marine Personnel 
Advisory Committee (MERPAC). The Manual reflects a synthesis of their 
recommendations and the medical requirements of title 46 Code of 
Federal Regulations (CFR) part 10, subpart C.
    Members of the public participated in the development of medical 
policy by providing comment and serving on working groups at the public 
meetings of MEDMAC and MERPAC. Additionally, the public had the 
opportunity to comment on drafts of policies contained in this Manual, 
and its predecessor, NVIC 04-08. See requests for comment on proposed 
policies regarding: Diabetes, cardiomyopathy, and sleep disorders (80 
FR 8586, Feb. 18, 2015); Medications (80 FR 4582, Jan. 28, 2015); 
Seizures (78 FR 17917, Mar. 25, 2013); and Implantable cardioverter 
defibrillators (77 FR 55174, Sep. 7, 2012). The Coast Guard considered 
these public comments when developing this Manual.

Public Comments on the Draft Merchant Mariner Medical Manual:

    The Coast Guard published a draft of the Merchant Mariner Medical 
Manual in the Federal Register and sought input from the public on the 
draft (83 FR 56272, Nov. 13, 2018). The current version of the Manual 
includes revisions made to address comments received in response to the 
Federal Register notification. While the Coast Guard is not required to 
seek or respond to public comments prior to publication of a policy 
document, we chose to do so in this case because of the perceived 
complexity of the Merchant Mariner Medical Manual, and because doing so 
provides us the opportunity to (1) create a guidance document that is 
more viable and responsive to the needs of the impacted community; and 
(2) to identify and clarify remaining areas of confusion and concern 
amongst the regulated community.
    The Coast Guard's notification sought general comments on the draft 
Medical Manual, with emphasis on suggestions to improve readability, 
clarity, and ease of use; and comments on whether the draft Manual's 
proposed medical certificate cancellation policy adequately addresses 
safety concerns in situations where the Coast Guard receives 
information indicating that a medical certificate holder has developed 
a medical condition that poses a significant risk of sudden 
incapacitation, or is taking a medication that poses a significant risk 
of impairment. The Coast Guard received 37 comment letters in response.

General Comments

    Ten comment letters provided a general opinion of the draft Manual, 
with the majority expressing an overall positive opinion. These 
commenters found the guidance in the Manual to be thorough, 
straightforward and easy to use, and they found that it answered many 
questions that had arisen with previous medical policy documents. The 
favorable commenters appreciated that the document provides medical 
evaluators, mariners and medical providers with needed and relevant 
information that will reduce the need for ``back and forth'' between 
the mariner and the National Maritime Center. They also found it 
helpful that the Manual outlines the Coast Guard's general concerns 
with particular medical conditions and discusses the general factors 
that the Coast Guard will use to evaluate the medical condition and 
make a fitness determination. Comments provided by the National 
Transportation Safety Board (NTSB) found that the draft Medical Manual 
aptly streamlines the medical certification guidance and provides a 
level of detail that should assist medical personnel during the mariner 
medical certification exams. The NTSB comment letter also provided the 
following observations:

    The combination of the Coast Guard's increased oversight of 
medical certification and development of medical guidance appears to 
be highly effective at addressing safety concerns regarding medical 
conditions that pose a significant risk of sudden incapacitation. 
Since 2009, the NTSB has not found any medical conditions to have 
contributed to the probable cause of a marine accident. However, the 
NTSB continues to find effects from impairing substances (alcohol 
and over-the-counter, prescription, or illicit drugs) to have 
contributed to the probable cause across all modes of 

    One comment letter expressed a generally negative opinion of the 
draft Medical Manual. This commenter expressed concerns that the 
guidance in the Medical Manual would sacrifice maritime safety unless 
the Coast Guard provided further clarification and a plan for 
implementation. Additionally, the commenter opined that the guidance 
does not adequately ensure that medical conditions are sufficiently 
controlled for those mariners at higher risk, because the Medical 
Manual does not establish clear standards for specific medical 
conditions. The Coast Guard does strive to increase clarity with 
publication of the Medical Manual, however, the Coast Guard disagrees 
that improved clarity requires publication of an implementation plan. 
Discussion of the Coast Guard's internal implementation plans are 
beyond the scope of the Medical Manual. Moreover, the majority of the 
policy contained in the mariner medical manual is not new guidance. It 
is the same guidance, explained in greater detail, that was already 
implemented in the years following the

[[Page 47143]]

publication of NVIC 04-08. The Coast Guard also disagrees with the 
assertion that the Medical Manual should establish condition-specific 
medical standards. The medical and physical standards for merchant 
mariner medical certification have already been established in 46 CFR 
part 10, subpart C. Establishing new medical standards is beyond the 
scope of a policy document.

Ease of Use and Clarity

    A letter from another commenter requested that the Coast Guard add 
an appendix that puts common conditions in a table format for quick 
reference, similar to that used in the International Maritime 
Organization's (IMO) Guidelines on the Medical Examination of 
Seafarers. The Coast Guard disagrees on the basis that a quick 
reference table would not adequately capture the discussion, 
explanation and rationale that mariners, treating providers and medical 
examiners need to understand in order to provide quality examinations 
to the Coast Guard.

Requirements for Medical Certification

    Three comment letters recommended that the Medical Manual provide 
additional medical requirements for medical certification. One letter 
commented that the Medical Manual should require all mariners to meet 
the same medical standard, and should provide ``specific acceptable 
parameters'' for many conditions to include BMI, pulmonary function, 
glucose levels, blood pressure, and cardiac function. Another comment 
letter suggested that the Coast Guard should implement a random medical 
testing program, similar to that used for drug testing. The third 
comment letter stated that the physical ability requirements should 
also include criteria for the speed and facility with which a mariner 
performs required tasks. The Coast Guard disagrees with these comments. 
While some of the recommendations pertaining to medical standards may 
warrant future discussion, changes or additions to the medical and 
physical requirements for medical certification are beyond the scope of 
this document. As discussed earlier, the medical and physical standards 
for medical certification are provided in 46 CFR part 10, subpart C, 
and changes to those requirements would require a rulemaking.

Guidance on the Conduct of the General Medical Examination

    One comment letter addressed the guidance pertaining to the general 
medical examination and recommended that the mariner medical 
examination include an evaluation of the mariner's oral/dental health 
condition to ensure that there are no untreated infections or other 
dental problems that could cause significant impairment while at sea. 
The Coast Guard agrees that such guidance may prove helpful and will 
work with MEDMAC to consider whether and what type of guidance would be 
appropriate for inclusion in a future version of the Medical Manual.

Frequency of Required Medical Examinations

    Four comments letters addressed the frequency of required medical 
examinations. Three commenters opined that it is excessive to require 
mariners to undergo a medical examination every two years. They 
recommended that the medical examination for all mariners, including 
those sailing under the authority of their Standards of Training, 
Certification, and Watchkeeping (STCW) endorsement, should remain valid 
for a period of 5 years, unless the mariner's medical condition 
warrants issuance of a shorter-duration medical certificate. A 
different commenter requested clarity on how often a mariner is 
required to obtain a medical exam, noting that in some instances 
maritime employers require an annual medical examination, even when the 
Coast Guard does not.
    The Merchant Mariner Medical Manual provides detailed discussion of 
medical examination and medical certification requirements for specific 
endorsements, and cites the corresponding regulatory references. It is 
important to note that the medical certificate validity period and the 
frequency of required medical examinations may differ between 
endorsements because of the differing legal requirements. Since these 
requirements are established in regulation, changing them would require 
a rulemaking and is beyond the scope of this policy document. The 
medical examination requirements of individual employers are also 
outside the scope of this policy document.

Medical Exam Forms

    One comment letter requested that the Medical Manual provide a list 
of medical examination forms that would be acceptable in place of the 
Form CG-719K or KE. The Coast Guard disagrees and did not provide a 
list of alternative forms because 46 CFR 10.302(a) requires the 
following: ``to qualify for a medical certificate, a mariner must 
provide evidence of meeting the medical and physical standards . . . on 
a CG-719-K or CG-719-K/E, as appropriate.''

Medical Examiners

    Ten comment letters provided comments on the topic of medical 
examiners. Three commenters requested additional information on the 
Designated Medical Examiner (DME) program, with one requesting that the 
Coast Guard publish its timeline and intent to create the DME program. 
The Coast Guard understands that there is significant interest in the 
DME program and will publish additional information, as and when 
    Five commenters recommended changes to the regulations regarding 
individuals who may perform examinations for purposes of the mariner 
medical certification examination. The Coast Guard considered each of 
these recommendations, but noted that changes to the regulations are 
beyond the scope of this policy document.

Internal National Maritime Center Processes

    Two comment letters requested that the Manual provide more detail 
on internal National Maritime Center (NMC) processes. One of these 
comments expressed concern that the Manual's instructions would allow 
non-medical personnel to make medical determinations for U.S. 
mariners.'' This commenter recommended that the Coast Guard add 
language to specify that all medical certification decisions will be 
supervised by a licensed medical officer. The second comment noted that 
the Manual does not contain ``any reassurance or check and balance of 
examiners, examination quality, or the NMC medical certification 
process.'' This commenter requested that the Coast Guard add language 
to address these concerns. The Coast Guard considered both of the 
comments, but does not concur with them. The staffing and internal 
quality assurance practices of the NMC are beyond the scope of this 
document. Nonetheless, the Coast Guard affirms that the activities of 
the NMC Medical Evaluations Division, particularly those related to 
medical certification, are supervised by a licensed medical officer. On 
the issue of providing quality assurance for medical examiners, it is 
important to recognize that medical examiners are not regulated by the 
Coast Guard. Therefore, providing reassurance or checks and balances of 
examiners and their exam quality, is inappropriate and is beyond the 
scope of this document.

Positive Drug Tests

    Two comment letters complained that the Manual does not provide 

[[Page 47144]]

for the evaluation of mariners who test positive for illegal drug use. 
One also requested that the Coast Guard add language to the Medical 
Manual requiring medical treatment for any mariner who fails a USCG 
required drug test. The Coast Guard does not concur with these 
commenters. The Medical Manual does not address requirements related to 
positive drug tests because the regulations and guidance on the 
management and disposition of individuals who have a positive drug test 
are contained in 46 CFR parts 5, 10, and 16. Changes to the DOT and 
Coast Guard drug testing regulation and policy are beyond the scope of 
this policy document. The Medical Manual contains guidance on how the 
Coast Guard will conduct the medical certification evaluation for 
individuals who have been diagnosed with a substance abuse disorder. 
The Medical Manual does not, however, direct treatment nor provide 
diagnostic instruction, because such areas are beyond the scope this 
policy document.

Reporting Material Changes in Medical Condition for Mariners

    One commenter asked whether a mariner who holds a medical waiver is 
required to report a material change in their medical condition. The 
Coast Guard notes that the answer to this question will depend on the 
provisions outlined in the mariner's medical waiver letter. Some waiver 
letters require that the mariner report changes in medical condition to 
the Coast Guard within a specified period of time. If no such provision 
is provided in the mariner's waiver letter, then the mariner is not 
required to disclose the change in medical condition until the time of 
the next medical certificate application.
    Three commenters asked whether employers have an obligation to 
report to the Coast Guard information regarding a change in condition. 
One of these same commenters also asked how employees could protect 
themselves from inaccurate reports. The Coast Guard considered each of 
these comments and advises that this manual does not impose any new 
reporting requirements on anyone. In response to the concerns about how 
mariners will be able to protect themselves from inaccurate reports, 
the Coast Guard offers that the Merchant Mariner Medical Manual only 
proposes to take action on medical information that the Coast Guard has 
determined as credible. The information that the Coast Guard would deem 
credible differs depending upon the circumstances, but generally will 
include medical provider documentation, formal incident reports, 
emergency medical services reports, and investigative reports. The 
Coast Guard also asserts that mariners will be able to protect 
themselves from inaccurate reports because this manual provides a 
standard process for evaluating these reports and further provides 
mariners with notice of, and the opportunity to respond to, information 
that indicates that they are no longer fit for medical certification.


    Two comment letters noticed discrepancies in the language in 
Chapter 7 related to required disclosures of over-the-counter (OTC) 
medications. One of the commenters also observed that the guidance in 
the Manual highlighted an error on the most recent version of the 
Application for Medical Certificate (Form CG-719K, Rev 04/17, Exp. Date 
03/31/2021) which incorrectly states that applicants must disclose all 
OTC medications taken within 30 days prior to the date the applicant 
signs the CG-719K. Both commenters noted that prior versions of the CG-
719K and the Medical Manual only instructed mariners to disclose OTC 
medications if the medications were used for a period of 30 days or 
more within the 90 days prior to the date the applicant signs the 
application to the Coast Guard. They requested that the Coast Guard 
provide additional language in the Medical Manual to clarify that 
applicants need only disclose OTC medications, when such medications 
were used for a period of 30 days or more within the 90 days prior to 
the date the applicant signs the application to the Coast Guard. The 
Coast Guard agrees that the language change regarding OTC medication 
disclosures on the most recent version of the CG-719K was an 
inadvertent change, and language was added to Chapter 7 of the Medical 
Manual to clarify the reporting requirements for OTC medications. The 
Coast Guard will be pursuing a change to CG-719K in the future to 
correct this change.
    Attendant with the language change regarding OTC medications, the 
Coast Guard also considered the NTSB's comments about impairing 
medication effects that have contributed to the probable cause of 
accidents across all modes of transportation. In light of these 
concerns, the Coast Guard determined that it would be prudent to add 
additional guidance regarding OTC medications to the Important Safety 
Warnings paragraph of Chapter 7. Specifically, the additional guidance 
warns that some OTC medications and preparations may contain 
intoxicants or other dangerous drugs prohibited by Department of 
Transportation regulations.

NMC Medical Evaluation Procedures for Mariners With Existing Waivers

    One commenter expressed confusion over the discussion of the term 
clear error in Paragraph I.3. of Chapter 3 of the Medical Manual. 
Paragraph I discusses NMC medical evaluation procedures for mariners 
with existing waivers, and Paragraph I.3. states that the Coast Guard 
is not bound to honor a medical waiver that was issued in clear error, 
contrary to duly promulgated policy in effect at time of issuance. The 
commenter mistakenly interpreted the clear error discussion to mean 
that the Coast Guard would not take responsibility for any erroneous 
certification decisions that might lead to mishaps or untoward medical 
situations at sea. In order to clear up this area of confusion, the 
Coast Guard added language to Paragraph I.3. of Chapter 3, to clarify 
that the discussion of clear error pertains to medical waivers that 
were issued in error.

Alternative Testing Methodologies for Color Vision

    One comment letter asserted that the discussion of alternative 
testing methodologies for demonstrating satisfactory color vision 
contained Paragraph A.1.d.(2)(c) contains an error because it indicates 
that the Farnsworth D-15 may be used as a potential alternative color 
vision test for Deck personnel. The Coast Guard disagrees. Title 46 CFR 
10.305(a) provides that mariners must demonstrate satisfactory color 
sense through one of the tests listed in the regulation, or through an 
alternative test acceptable to the Coast Guard. Paragraph A.1.d.(2) of 
the Medical Manual provides guidance for mariner applicants seeking to 
demonstrate satisfactory color vision sense through use of an 
alternative test, and describes the type of information that the Coast 
Guard will consider in determining whether an alternative test is 
sufficient for issuance of the medical certificate. The guidance does 
not guarantee that any singular test will be accepted as an alternative 
methodology for any particular mariner applicant, but rather states 
that the Coast Guard retains final authority for determining whether 
the testing is acceptable, and recommends that any alternative test be 
accompanied by a formal color vision evaluation from an ophthalmologist 
or optometrist.

[[Page 47145]]

Coast Guard Mission and Motives With Respect to Medical Credentialing

    One commenter asserted that the Coast Guard should ``consider its 
mission and motives with respect to medical credentialing,'' and 
expressed displeasure that the Medical Manual focuses on ``medical 
credentialing without making any decisions on mariner fitness for 
duty.'' The Coast Guard considered this commenter's concerns and noted 
that the Medical Manual's purpose, as stated in Paragraph 1 of the 
Letter of Promulgation for the Merchant Mariner Medical Manual, is to 
``provide guidance for evaluating the physical and medical condition of 
applicants for merchant mariner medical certificates.'' The Coast Guard 
also notes that making a determination of fitness for certification is 
distinctly different from making a determination of fitness for duty, 
and refers the reader to the discussion that follows.
    Fitness-for-certification. The medical and physical standards for 
merchant mariner medical certification are contained in 46 CFR part 10, 
subpart C. The Coast Guard mariner medical evaluation and certification 
process seeks to determine whether an applicant meets the medical and 
physical standards for merchant mariners based upon the information 
available to the Coast Guard at the time of the certification decision. 
In accordance with 46 CFR 10.301, the Coast Guard will issue a medical 
certificate to a mariner meeting the medical and physical standards for 
merchant mariners. This decision is necessarily a snapshot of the 
mariner's medical and physical condition at a single point in time.
    Fitness-for-duty. In general, fitness for duty refers to an 
employee's ability to perform his/her essential job functions, as 
specified by the employer, without impairment from medical conditions 
or medications. There are some important considerations with respect to 
fitness for duty. First, an individual's fitness-for-duty status is not 
static, thus it should be considered whenever an individual reports for 
duty. Fitness-for-duty status can change suddenly due to an acute 
illness, injury or incident. As an example, an individual with no 
medical problems who has been issued a medical certificate and who 
normally performs their essential job functions without impairment, 
could become ``not-fit-for duty'' because of an impairing illness such 
as the flu, and/or due to impairing medications used to treat an acute 
illness. The second important consideration is that a ``fitness-for 
duty'' determination refers to an evaluation ordered by an employer to 
assess an employee's ability to perform the essential functions of 
their assigned job (as specified by the employer). Such an evaluation 
might be requested when the employer has a reasonable belief that an 
employee will not be able to perform essential job functions because of 
their medical condition. A variety of state and Federal laws govern 
fitness for duty determinations depending upon the specific 
circumstances. Generally, a fitness for duty physical must be job-
related and consistent with business necessity. One other important 
consideration is that the merchant mariner medical qualification 
standards in part 10, subpart C, are the minimum acceptable standards. 
Some maritime employers may choose to establish medical and/or physical 
ability requirements for their employees that are more stringent than 
the Coast Guard medical certification standards based on factors such 
as specific duty requirements, austere work environments, and 
operational tempo. In these cases, the employer's fitness-for-duty 
determinations may differ from the medical certification determination 
because they are based upon different standards. The Merchant Mariner 
Medical Manual does not preclude marine employers from establishing 
more rigorous medical or physical ability guidelines; however, there 
are additional laws and regulations that apply.

Line-by-Line List of Changes

    Two commenters requested a detailed, line-by-line list of proposed 
changes that compares the current language in NVIC 04-08 with each 
change, addition and deletion made in the Medical Manual. The Coast 
Guard considered this comment, but determined that a line-by-line list 
of changes would not be helpful because of the extensive changes in 
wording, format and organization between the two documents. Instead, 
the Coast Guard has already provided a fairly comprehensive discussion 
of the major changes in Paragraph 6 of the Letter of Promulgation for 
the Medical Manual.

Medical Certificate Cancellation

    Commenters were both supportive of, and objected to, the proposed 
medical certificate cancellation policy. After considering the 
comments, we decided to proceed with the proposed policy. One commenter 
who opposed the policy nevertheless provided a number of suggested 
edits to the text which were adopted. Those opposed to the cancellation 
policy suggested the Suspension and Revocation (S&R) process (46 CFR 
part 5) as an alternative. The Suspension and Revocation (S&R) process 
has limited jurisdiction over mariner medical issues. On this subject, 
S&R is authorized in circumstances where a credentialed mariner has 
committed an act of incompetence relating to the operation of a vessel 
(see 46 U.S.C. 7703(4)). A mariner having a disqualifying medical 
condition is not something addressed through S&R unless and until it 
has impacted vessel operation. Accordingly, the medical certificate 
cancellation and waiver processes set forth in the manual effectively 
address mariner medical qualification and fitness for duty concerns in 
ways that the S&R system cannot. There are also situations such as 
mariners using dangerous drugs or operating vessels under the influence 
of alcohol or other intoxicants that present both medical qualification 
and S&R concerns, so it may be appropriate for the Coast Guard to 
utilize both the procedures set forth in this manual and the S&R 
process to address and resolve these issues in the interest of safety.

Waivers, Limitations, Restrictions

    One commenter requested more detail on limitations and 
restrictions. The commenter noted that waivers seem not to have been 
consistently applied to conditions. The Coast Guard agrees in part and 
over the last few years has provided further guidance on waivers for 
the most frequently occurring conditions. Those changes to NVIC 04-08 
have been carried forward into this manual.

Process for Removing Waivers, Limitations and Restrictions

    One commenter complained that the process for removing restrictions 
and waivers ``seems uncomfortably weighted toward taking away one's 
ability to sail, without considering that many conditions--even very 
serious ones--are temporary in nature.'' The Coast Guard disagrees and 
notes that the Medical Manual provides specific guidance on medical 
evaluation procedures for mariners with short-term conditions (see 
paragraph J. of Chapter 3 of the Medical Manual). These provisions were 
included to reduce the burden of imposing and then removing waivers and 
restrictions for conditions that are expected to resolve in the short-
    This document is issued under the authority of 5 U.S.C. 552(a), 46 
U.S.C. 7101, and 46 U.S.C. 7302.

[[Page 47146]]

    Dated: September 3, 2019.
J. G. Lantz,
Director, Commercial Regulations and Standards, U.S. Coast Guard.
[FR Doc. 2019-19370 Filed 9-6-19; 8:45 am]