c HEAD OFFICE CONTIGENCY PSMM/HOCP-05

PLAN Version : 00
PROCEDURE : HEAD OFFICE CONTIGENCY
Date: 04.01.2022
PLAN Page: 1/ 1

EMMERGENCY INFORMATION FOR MEDICAL SERVICE

(For reporter to fill up)

1. Name of reporter
a) Name .......................................................................................................
b) Rank : ......................................................................................................
c) Ship Name :..............................................................................................
d) Communication mean :............................................................................
2. Name of patient
a) Name :......................................................................................................
b) Rank :.......................................................................................................
c) Age :.........................................................................................................
d) Ship Name :..............................................................................................
e) Call Sign :.................................................................................................
3. Location of patient
a) City/ province:..........................................................................................
b) Next of kin :..............................................................................................
c) Address:....................................................................................................
4. Have patient got doctor’s exam ? Yes /No
5. Name of doctor :..................................................................................................
Telephone :.........................................................................................................
6. Medical situation
Is the patient in these situation?
a) conscious Yes/ No
b) Confused or anxious Yes/ No
c) Dyspnea Yes/ No
d) Much blood leaking Yes/ No
e) Chest pain Yes/ No
f) Burned Yes/ No
g) Bone broken Yes/ No
h) Pain in belly Yes/ No
h) Trauma Yes/ No
i) High fever Yes/ No
j) Vomit Yes/ No
k) Pregnant Yes/ No

7. Comment :

PVTRANS SHIPS MANAGEMENT CO. – PSM