ILLNESS AND INJURY REPORT

Patient Information Name: NARWDA PASWAN Age: 32 Nationality: INDIAN Area of Assignment: CORRIDOR BADGE NO.: JBOG 80273 Position: CARPENTER Company: QCON

JBOG Recovery Project

Reported to GV Camp Clinic: 12-08--2012 6:50 H ROOM NO: C5 23 FF3 MOBILE NUMBER: 77825630

Section A. To be filled by the Doctor:

CHIEF COMPLAINT: For T.T Injection, second dose Sick Leave: (Pls. tick) BP - 114/75 T - 36.3 P - 74 6:55 - To Al Madina QRC/Flour nurse informed 9:55 - comeback with meds 1. Diclofenac Sodium 50mg 1 tab BID QRC/Flour nurse informed Yes If yes, no. of days: No

ristan Palacpac

Classification: (Pls. tick) Work-related Injury Work-related Illness Non-work-related Illness/Injury

Referral: (Pls. tick) Yes If yes, referred to: __________________

Attended by: JUNEL TRISTAN PALACPAC - GV MAC NURSE JBOG Recovery Project

RLIC/Al Madinah Medical Center Al-Khor Hospital Hamad Medical Center

Note: Please attach all relevant documentation including sick leave forms issued by RLIC, Al-Khor Hospital, etc. before forwarding to HSE for classification.

Section B. To be filled by Health Safety and Environment (HSE) Manager

Classification: (Pls. tick) First Aid Medical Treatment Restricted Work LTA

If LTA, how many days?

If Restricted Work, state details:

Comments / Justification of Classification:

Classified by:

Section C. Return To Work (RTW) Certification - To be filled by JBOG Recovery Project Doctor Comments: (Please provide details) Fit to return to work Unfit to return to work Reassignment

Important: Please fax signed copy to Qatargas Medical Center at 4473-6189.