ILLNESS AND INJURY REPORT

Patient Information Name: RAMAWATAR LAL Age: 32 Nationality: Indian Area of Assignment: CORRIDOR Section A. To be filled by the Doctor: Position: MASON Company: QCON BADGE NO: JBOG-80044

JBOG Recovery Project

Incident 00/08/2012 Time of Incident: 0000 HOURS Reported to GV Camp Clinic: 26/08/2012 at 19:20 Hrs. ROOM NO: C 5 16 GF 2 MOBILE NUMBER:

CHIEF COMPLAINT: SKIN ITCHINESS - BOTH HANDS X 1 YEAR Sick Leave: (Pls. tick) Seen and examined QCON NURSE - JAYSON AVILA VS: BP: 110/80 Hx - was previously sent to AL RAFA POLYCLINIC PR: 58 T: 37.2 19:20- Seen at GV MAC BP: 122/79 PR: 63 T: 36.8 (+) skin lesions- (irregular border) Yes If yes, no. of days: No

> Sent to RLMC/ALMADINA for further management >QRC/FLUOR NURSE INFORMED 20:15:Cameback to GV MAC Home meds 1. Clobetasol 0.05% ointment; 1 application BID 2. Desloratidine 5 mg 1 tab OD 3. Multivitamins 1 tab OD >QRC/ FLUOR NURSE INFORMED

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: NIKKO ANDREW B. PIGTAIN - 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.