Saturday, December 19, 2015

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/seamans 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