SHIP MASTER’S MEDICAL REPORT

(for compliance with Regulation 4.1 of the Maritime Labour Convention, 2006)

Date of report
Ship's identity and navigation status
Name
Owner
Name and address of on-shore agent
Position (latitude, longitude) at onset of illness
Destination and ETA (expected time of arrival)
The patient and the medical problem
Surname and first name
Sex	Male   Female
Date of birth (dd-mm-yyyy)
Nationality
Seafarer registration number (if any) or passport/seaman’s book number
Shipboard job title
Hour and date when taken off work
Hour and date when returned to work

Injury or Illness

Hour and date of injury or onset of illness
Hour and date of first examination or treatment
Location on ship where injury occurred
Circumstances of injury
Symptoms
Findings of physical examination
Findings of X-ray or laboratory test
Overall clinical impression before treatment
Treatment given on board
Overall clinical impression after treatment

Telemedical consultation

Hour and date of initial contact
Mode of communication (radio, telephone, fax, other)
Surname and first name of telemedical consultant
Details of telemedical advice given

* Attach all relevant medical reports to this report form