Template No: WBI T16

Issue Date: 06.Aug.2013

Workboat International DMCCO Rev No: 00
Rev Date: NYR

MEDICAL REPORT

1) Vessel Name 2) Port of Call 3) Date of Illness / Injury

4) Surname of Patient 5) Other Name(s) 6) Date of Birth

7) Nationality 8) Job Title 9) Seamen Book No.

9) Details of Injury and Treatment given on board

10) Was Log Entry made
No Yes

11) Masters Signature 12) Masters Name 13) Date signed by Master

14) Ship Agent Name and Address

TO THE DOCTOR:
Please see this patient and complete this form. Retain a copy for your records and return the original to the Master or Agent
for onward despatch to Operations Manager.

15) Accident at work 16) Illness 17) Dental

No Yes No Yes No Yes

18) Diagnosis and treatment given 19) Infectious Disease

No Yes

20) Was the patient previously ill with the same symptom (in last 3 month)
No Yes (If yes give details)

21)
Fit for normal work

Unfit for normal work but fit for restricted work

22)
Unfit for normal work For how many days

Bed rest necessary For how many days

To be signed off work

And repatriated Air transport required No

And go to hospital Yes

23) The patient was seen on (Date):

In Doctors Office Charges:

On board vessel Copy of the invoice must follow

Elsewhere

24) Doctors Name, Address and Telephone number:

Doctors Signature:

TO BE COMPLETED ONLY IF CREW MEMBER IS SIGNED OFF

25) Port of Discharge 26) Date of Discharge 27) Domicile

28) Name of Employer or Manning Agency

29) Name of Hospital or place where crew member is staying

30) Disposal of Effects

Original: WBI Operations Department Copy: Doctor Copy: Vessels File