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ANNEX 7A-1

MEDICAL CLEARANCE FORM PART I – MEDIF I

茲同意透過此申請書提供個人資料為本次航空運輸使用。關於個人資料蒐集及使用，請參閱越南航空官網「隱私
政策」。

PART I 第一部分 - Answer ALL questions. 請回答所有問題

To be completed by
- Put a cross “X” in “YES” or “NO” boxes. 請以 ☒標示正確選項
PASSENGER
- Use BLOCK LETTERS when completing this form.請以英文大寫字母填寫所有資訊
由旅客填寫

A Passenger ‘s full name: Male 男 Female 女 Age 年齡:.........

旅客姓名
Itinerary 行程:
Flight No 航班號碼……….....Class艙等......................Date日期...................... Origin出發地……........Destination目的地…............
B Flight No 航班號碼……….....Class艙等......................Date日期...................... Origin出發地……........Destination目的地…............
Flight No 航班號碼……….....Class艙等......................Date日期...................... Origin出發地……........Destination目的地…............

MEDIF II needed? 是否需

C Nature of Medical Condition/Incapacitation病名及詳細症狀: 填寫表單二
No 否 Yes 是
D Is stretcher needed on board是否需求機上擔架? No 否 Yes 是

Intended Escort ‘s full name護送人姓名:........................................................ Male 男 Female 女 Age 年齡:.........

Professional qualification 護送人背景:...............................(If untrained, state: “TRAVEL COMPANION” 請註明是否為專業護理或
E 醫療人員，若僅為一般同行人員，請填寫TRAVEL COMPANION).
Telephone/Moble phone市話/行動電話:.................................................................................................................................................
If passenger with vision/hearing impairment, please state if escorted by trained dog若旅客為聽障或視障人士，請標示是否同時有協
助犬上機需求? No 否 Yes是
Wheelchair services by Vietnam Airlines needed是否需求輪椅? Own wheelchair是否自備輪椅? No 否 Yes是
No 否 Yes是 If YES, wheelchair type若為是，請標示下列選項:
If YES, service type若為是，請標示下列選項: 1.Collapsible 折疊式 No 否 Yes是
F To boarding gate/ to aircraft step乘坐至空橋/登機梯 2. Power driven 電動式 No 否 Yes是
To aircraft door乘坐至登機門 3. Spillable battery 溢漏式(濕)電池 No 否 Yes是
To seat and inflight乘坐至機上座位 4. Other type, specify其他類型:..............................................

Ambullance needed是否需求救護車? No 否 Yes 是 (Passenger/Escort is responsible for making all ambullance arrangements旅客/
護送人需自行安排救護車接送)
Ambullance company contact救護車承攬方聯絡方式:
G
Origin contact出發地聯絡人:............................................................ Telephone/Moble phone市話/行動電話:...........................................
Destination contact目的地聯絡人:................................................... Telephone/Moble phone市話/行動電話:...........................................

If YES, specify below and idicate for each item若標示「是」，

請提供下列資訊:
(a) The ARRRANGING airlines or other organization安排服務之
航空公司或機構名稱
Other ground arrangement needed是否需要其他地面協助? (b) At WHOSE expense付款方
NO否 Yes 是 (c) CONTACT addresses/phones where appropriate or whenever
specific persons are designated to meet/asssist passenger接/送機聯
H 絡人電話與地址.
1. Arrangements for drop-off delivery No 否 Yes 是
Details請詳述:
at DEPARTURE airport是否於出發地機場需求特殊協助.
2. Arrangements for assistance No 否 Yes是
Details請詳述:
at CONNECTION point 是否於轉機點機場需求特殊協助.

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3. Arrangements for pick up No 否 Ye是

Details請詳述:
at ARRIVAL point是否於目的地機場需求特殊協助.
4. Other requirement No 否 Yes 是
Details請詳述:
or relevant information是否需求其它相關協助.
Special In-flight arrangements needed是否需求機上特殊協助? If YES, describe and indicate for each item若標示「是」，請提
供下列資訊:
No Yes (a) Special service type and segment(s) on which required需求特
(e.g:special meal, special seating, extra seat, medical equipments(*), assistances with
medications,special baggage…特殊餐食、座位安排/額外座位、醫療設備(*)與協助、 殊協助之種類與航段.
I 特殊行李) (b) Airline – arranged or arranging third party安排服務之航空公
Details:............................................................................................... 司或第三方承攬單位.
(*) Provision of special equipment such as oxygen etc. always require completion of Part (c) At whose expense付款方
II. See NOTE at the end of Part II若需求特殊設備如氧氣瓶，請填寫詳細資訊於表單
二.

PASSENGER ‘S DECLARATION旅客聲明
I take note that, if acccepted for carriage, my journey will be subject to the general conditions of carriage/tariffs of Vietnam Airlines and
that Vietnam Airlines does not assume any special liability exceeding those conditions/tariffs. I am prepared, at my own risk to bear any
J consequences which carriage by air may have for my state of health and I release Vietnam Airlines, its employees, servants and agents
from any liability for such consequences.立書人業已詳悉越南航空所訂定之運送規則或辦法，茲同意免除、返還及賠償越南航
空及其董事、高級職員、代理人或受雇人因執行本次運送所發生、負擔或應給付之任何責任、訴訟、損失、損害、成本及
費用。
Address地址 Date日期 Passenger or authorized person ‘s signature and full name
旅客簽名

ANNEX 7A – 2

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ANNEX 7A – 3

USEFUL INFORMATION TO PASSENGER REQUIRING WHEELCHAIR SERVICES

Dear Passenger,
Vietnam Airlines’ wheelchair service is the service offered to disabled or reduced mobility
passengers (hereinafter refered as “Passenger”) travel on Vienam Airlines operating flights.
Vietnam Airlines arranges staff and uses highlift cars, loading bridges, other specialized facilities,
etc. to assist passenger to ascend/descend steps, to/from the aircraft and to/from their seat.
In fact, above mentioned specialied facilities are not available at some departure and arrival
station (*). In these case, Vietnam Airlnes’ ground handling staff and passenger‘s escort (if any)
assist passenger to ascend/descend steps.
Your kind understanding is highly appreciated. Thank you and have a good flight.
(*) List of airports are not equipped specialied facilities:
Cat Bi airport – Hai Phong, Tho Xuan – Thanh Hoa, Vinh airport – Nghe An, Phu Bai - Hue,
Dong Hoi airport – Quang Binh, Phu Cat airport – Quy Nhon, Tuy Hoa airport – Phu Yen, Lien
Khuong – Da Lat, Pleiku Airport – Gia Lai, Buon Me Thuot airport – Dac Lac, Can Tho airport –
Can Tho.

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ANNEX 7A – 4

CONSENT FORM - UMNR GIẤY ỦY QUYỀN – TRẺ EM ĐI MỘT MÌNH

I the undersigned parent or guardian authorize Vietnam Airlines to
carry minor (full name)
.........................................................................................................
on Vietnam Airlines’ flight(s).
I confirm that I have arranged for the above mentioned minor to be
accompanied to the airport on departure and to be met at transfer
point by the persons named. These persons will remain at the
airport until the flight has departed and/or be available at the airport
at the scheduled time of arrival of the flight.
Should the minor not be met at transfer point or destination, I
authorize the carrier(s) to take whatever action they consider
neccessary to ensure the minor's safe custody including return of
minor to the airport of original. I agree to idemnify and reimburse
the carrier(s) for the cost and expenses incured by them in taking
such action.
Tôi, người ký tên dưới đây, là cha mẹ hoặc người giám hộ đồng ý ủy quyền
cho Vietnam Airlines vận chuyển trẻ em (ghi họ, đệm, tên)
..........................................................................................................................
trên (các) chuyến bay của Vietnam Airlines.
Tôi cam đoan rằng tôi đã thu xếp những người có tên trên đưa đón trẻ em có
tên trên tại điểm khởi hành, điểm nối chuyến và điểm đến. Người đưa đón trẻ
sẽ ở lại sân bay cho đến khi máy bay cất cánh và có mặt tại sân bay theo giờ
hạ cánh dự kiến của chuyến bay.
Nếu trẻ em trên không được đón tại điểm nối chuyến, điểm đến như dự định,
tôi ủy quyền cho Vietnam Airlines hoặc (các) nhà vận chuyển khác liên
quan toàn quyền làm các việc mà họ cho là cần thiết để bảo vệ an toàn cho
đứa trẻ, kể cả việc đưa đứa trẻ quay trở lại sân bay khởi hành ban đầu. Tôi
đồng ý miễn trừ trách nhiệm và bồi thường, hoàn trả cho Vietnam Airlines và
(các) nhà vận chuyển liên quan các chi phí phát sinh do việc thu xếp các
việc cần thiết trên.

I certify that the minor is in possession of all travel documents Tôi xác nhận rằng trẻ em trên có đầy đủ giấy tờ tùy thân hợp lệ (hộ chiếu, thị
(passport, visa, health certificate, etc.) required by applicable laws. thực, chứng nhận sức khỏe...) Tôi cam đoan rằng những thông tin cung cấp
I agree to and minor named above and certify that the information trên đây là chính xác.
provided is accurate.

Full Name/Họ, đệm, tên:

Singature/ Chữ ký

Date/Ngày, tháng, năm:

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PHỤ LỤC 7A – 5

PHIẾU VẬN CHUYỂN TRẺ EM ĐI MỘT MÌNH

HANDLING ADVICE FOR UNACCOMPANIED MINOR
TÊN TRẺ Giới tính NGƯỜI ĐƯA TRẺ ĐẾN ĐIỂM KHỞI HÀNH CHỮ KÝ
EM Sex PERSON MEETING OFF ON DEPARTURE SIGNATURE
MINOR’S Tên/Name
FULL NAME
Ngày sinh Date of birth Tuổi Age Điện thoại Phone No
TÊN CHA MẸ PARENT’S NAME Số chứng minh/Hộ chiếu Identify card/Passport No.
Địa chỉ Address Địa chỉ Address
Điện thoại Phone No
TÊN NGƯỜI GIÁM HỘ GUARDIAN’S NAME NGƯỜI ĐÓN TRẺ TẠI ĐIỂM ĐẾN CHỮ KÝ
PERSON MEETING ON ARRIVAL SIGNATURE
Địa chỉ Address Tên/Name
Điện thoại Phone No
Chuyến bay Flight NgàyDate Từ From To Đến Điện thoại Phone No
Số chứng minh/Hộ chiếu Identify card/Passport No.
Địa chỉ Address

Airline staff in charge of minor whilst in their custody (Signature, Name, Department)
Ground staff
Ground staff at departure Cabin crew on 1st flight Ground staff at transfer Cabin crew on 2nd flight
at arrival

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ANNEX 7A – 6

WAIVER OF RESPONSIBILITY

Passengers’s full name: .....................................................................................................................................................

Pasport/Identify card number: ..........................................................................................................................................
I hereby consent that I have been informed about the results of the travel and/or carriage of passenger and baggage
by Vietnam Airlines due to the conditions specified below:

(Select the appropriate box):

1. Health status; current or mental or physical state of Passenger which may involve any hazard
of risk to crew, passengers, baggage on the same flight.
Specify:...............................................................................................................................................

2. Conditions on documents, security, customs immigration required by airlines or at airports,

nations in the whole routing.
Specify:................................................................................................................................................

3. Feature, internal material of the baggage; baggage packing.

Baggage tag number: ..........................................................................................................................

4. Conditions of animal’s health, documents, kennel required by airlines or at airports, nations in

the whole routing.
Description of animal (weight, age, color, species, health state, offensiveness, pregnancy ...):
.............................................................................................................................................................

5. Other conditions:
Specify: ..............................................................................................................................................

Flight information:

Flight number Date From To

Flight number Date From To
Flight number Date From To

I agree to release and discharge Vietnam Airlines, their agents, officers and employees from any and all liability
which may be consequential as the result of the travel and/or carriage of passenger and baggage by Vietnam Airlines
as specified above.

I further agree to indemnify and hold Vietnam Airlines any and all action, claims and proceeding against VNA by
any third party or parties including all costs, losses, damages, charges and expenses incidental thereto which may be
suffered by Vietnam Airlines as the result of the travel and/or carriage by Vietnam Airlines specified above due to
condition specified below and any possible consequence thereof.

Date: ................................................

Signature and full name of Signature and full name of passenger/parents/authorized person
Vietnam Airlines’ representative

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PHỤ LỤC 7A – 7

GUIDANCE TO THE PHYSICIAN

* Conditions involving in air travel:

Civil aircraft fly at an altitude of 7.000-12.000 meters through the stratosphere at almost the
speed of sound 900km per hour. At high altitude where barometric pressure is much lower than
on the ground, aircraft cabin is mechanically pressurized during the flight. The cabin air pressure
during the cruise is maintained at equivalent to that of 1.500-2.000 meters height mountain top.
Particularly, cabin air pressure changes greatly during 15-30 minutes after take off and before
landing. Therefore, it should be noted, in diagnosing the incapacitated passengers, that the
following conditions will be produced in aircraft cabin:
1. Comparative low pressure in the aircraft cabin: as air pressure become lower, internal gas in
human body expands. The gas trapped in the body and which does not get discharged expands
during the flight. This may put pressure on affected parts or internal organs and may cause pain
and/or breathing difficulty.
2. Comparative low oxygen concentration: Passengers (patients) having problem with respiratory
organs, heart, cerebral blood vessel and serious anemia will be influenced by decreasing oxygen
concentration in the high altitude. Also women in the late stage of pregnancy and new born
babies may be affected.
3. Light turbulence (could cause uneasy felling)
4. The safety and control of other passengers to be considered.
5. In spite of the foregoing, the fact that in some occasions, the passenger may have to be carried
when the saving of the passenger’s life is involved.
* Guiding principles in deciding whether or not a person is physically and mentally fit to
travel by air:
Persons under following conditions are generally considered unfit for air travel on Vietnam
Airlines:
1. Those suffering from severe and critical heart disease: e.g. severely decompensated cardiac
failure, cyanotic conditions or myocardial infraction (those who had an attack within the past 6
weeks are not acceptable even if the infraction was minimal).
2. Those suffering from severe disease or lesion of respiratory organs, which cause severe
dyspnea, those patients with entrapped gas such as a recent spontaneous preumothorax or who
may has residual air in nerve system after medical examination such as encephalopneumography
or ventriculography; deep sea divers are not acceptable for air travel within 24-48 hours of a deep
dive or working in scuba room.
3. Those with lesions that may cause reiterate hemoptysis, hematemesis, melena, vomiting or
severe groaning.
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4. Those with cerebral apoplexy (those who had an attack within pas 4 weeks are not acceptable).
5. Those with large mediastinal tumors, extremely large unsupported hernias, intestinal
obstruction.
6. Those with cranial diseases, cephalic lesions resulted in increased intracranial pressure,
fracture of the skull and those with recent fracture of the mandible with permanent wiring of the
jaw.
7. Those who have severe anaemia with Hemoglobin level less than 8g/dl.
8. Those suffering from severe otitis media and sinusitis with blockage of the Eustachian tube.
9. Those who have not completely recovered from surgery (because of insufficient time for the
wounds to close) of head, chest or abdomen: within 10 days of simple abdominal operations and
21 days of chest surgery; or women in the immediate afterbirth.
10. Person obviously under the influence of alcohol, drugs or other narcotics; those mentally ill
and medical condition is unstable, who may be hazardous to others and/or to themselves.
11. Recent cases of poliomyelitis at any time unless special arrangements are made with the
carrier.
12. Person with skin diseases that are contagious or repulsive in appearance or smell that may
cause discomfort to other passenger.
13. Persons who are suspected or suffering from infectious diseases: e.g. cholera, dysentery,
typhoid fever, paratyphoid fever, eruptive typhoid, smallpox, scarlet fever, diphtheria, plaque,
epidemic meoningoencephalitis, Japanese encephalitis, active tuberculosis (infectious) or any
other epidemic infections or any contagious diseases are not acceptable for air travel.
14. Infant within 07 days of birth.
15. Pregnant women beyond the thirty-second week.
* Note: However, with a particular case, if the medical condition or the state of health of the
person is considered stable and the attending/examining physician certifies the person fit for
air travel with prognosis and escorted by an attending physician who is responsible for take
care patient, he/she may be assessed by the airline for acceptation for air travel

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ANNEX 7A-8

Handling Advice for Passengers with disabilities

Vietnam Airlines always do our best to help disabled passengers that need assistance. Please
inform our branch offices of any special assistance you may require while travelling with us.
The following information outlines a number of the services that Vietnam Airlines offers
customers with a disability. If our passengers travel with mobility aids, we have attached a check
list of questions which will assist us to ensure that your journey is as smooth as possible. This
brochure can be accessed and downloaded from website vietnamairlines.com

1. LET US ASSIST YOU

- If you would like assistance during your travel with us, let us know the level of assistance
you require at the time of booking.
- If you book via vietnamairlines.com, contact your local Vietnam Airlines branch office
immediately after you have made your booking to advice us of any specific requirements.
- Passenger with disability generally do not require medical clrearance that they are not fit
for travel. However, if you require more information on whether you require medical
clearance, please access vietnamairlines.com or call Vietnam Airlines Branch office.
2. Check in time

You are advised to come to the airport early with sufficient time to check-in with priority boarding
service and have your wheelchairs and/or supportive devices well-packaged and checked.

- At least 1 hour prior to departure for domestic routes.

- At least 2 hours prior to departure for international routes.

*We offer special check in counter “Special Service Counter” at some airports.

Passenger with disability will not be allocated an exit row seat due to civil aviation safety regulations.
You are requested to sit upright in a straight-back seat with seat belt fastened. Flight attendants
will assist you between your seat to and from the aircraft lavatory. At your request, our cabin
crew can help you write your embarkation form if you fly on international routes

3. Priority boarding service

Vietnam Airlines offers priority boarding for passengers with physical challenges Please contact our staff
near the gate for this service.

- Vietnam Airlines offers priority boarding for passengers with disabilities. Please contact
our staff near the gate for this service. Passengers must be at the boarding gate at least 40
minutes prior to departure. At some airports such as London Heathrow (UK), Paris Charle

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De Gaulle (France) , Frankfurt (Germany) … passengers must be present at the boarding

gate at least 60 minutes prior to departure.
4. In the Cabin

● You are requested to sit upright in a straight-back seat with seat belt fastened. (*)
● Flight attendants will assist you between your seat to and from the aircraft lavatory.
● Flight attendants on international routes can help you write your embarkation form.

Important information:

While our cabin crew will do everything possible to provide assistance to passengers during the
flight, please note that we are unable to provide passengers with any assistance for personal care
needs such as feeding, elimination functions including assistance inside the lavatory or other
personal care needs. Additionally, cabin crew are trained only in FIRST AID and are NOT
PERMITTED to administer any injection or medication.

Special meals

If you have meal preference, please request Special Meal upon reservation.

5. Upon Airport Arrival

Vietnam Airlines offers with a wheelchair at the arrival airport. Our airport staff or your
escort will help to physically carry you down the stairs upon boarding and deplaning the
aircraft, if requested.
- On arrival, at your request, we can assist you with flight connections and baggage
transfer.
- At some airports, specialied facilities are not available at some departure/destination.
Vietnam Airlnes’ ground handling staff assist passenger to ascend/descend steps, to/from
the aircraft and to/from their seat.

6. Mobility Aid Services

Vietnam Airlines offers the following Mobility Aid services:

- Service for passengers who are blind or vision impaired – free of charge;
- Service for passengers who are deaf or hearing impaired – free of charge;
- Service for passengers who are using wheelchair – free of charge;
- Accompanying cabin crew service – fee applied.
7. Travelling with companion and supportive devices

Travelling with an escort

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Passengers with disabilities are highly recommended to travel with an escort. Please let us know
if you travel alone or travel with your companion at the time you make reservation.

Travelling with a service dog

A service dog for disabilities is accepted free of charge. If passenger is accompanied with seeing
eye dog, let us know at the time of booking.

Travelling with supportive devices

Walking aids such as canes and crutches can be carried onboard. These need to be small enough
to be stowed under your seat or in the overhead compartment, not to protrude into any seating
row floor space or main aisle.

Travelling with your wheelchair

Vietnam Airlines accepts wheelchair you are using free of charge. Please advise us information
upon your reservation.

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ANNEX 7B – 1
1. Authorization on Handling Special Service on VNA operating flight:
SPECIAL SERVICE HANDLING AUTHORIZATION
VNA MARKETING
CODE CASE BRANCH SERVICE
OFFICES DEPARTMENT
Accompanied passsenger x (automatic)
1. BLND Unaccompanied passenger x (automatic)
Accompanied cabin crew service x
2. BSCT x (automatic)
Accompanied passsenger x (automatic)
3. DEAF Unaccompanied passenger x (automatic)
Accompanied cabin crew service x
4. EXST x
Special service not required or
5. MEDA x
WCHR/WCHS/WCHC request only
6. OXYG x
Special service not required or
x
7. PREG WCHR/WCHS/WCHC request only
Accompanied cabin crew service x
8. SPML x (automatic)
9. STCR x
10. UMNR From 6 years of age up to under 18 years of age x
From 2 years of age up to under 6 years of age x
Accompanied cabin crew service x
11. WCHC x
12. WCHR x (automatic)
13. WCHS x
14.WCHR/
WCHS/ Accompanied cabin crew service x
WCHC

SPECIAL BAGGAGE HANDLING AUTHORIZATION

No CODE VNA BRANCH MARKETING
CASE OFFICES SERVICE
DEPARTMENT

1 AVIH x

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2 PETC x
3 CBBG x
Weight does not exceed 32kg and/or
x
4 BULK size is within limitation
Weight and/or size are over limitation. x
Weight does not exceed 32kg and/or
x
5 BIKE size is within limitation
Weight and/or size are over limitation. x
Weight does not exceed 32kg and/or
x
6 SPEQ size is within limitation
Weight and/or size are over limitation. x
Weight does not exceed 32kg and/or x
Personal
7 size is within limitation
wheelchair
Weight and/or size are over limitation. x

2. Authorization on Handling Special Service on VNA marketing flight: Send request to

Marketing Service Department.

ANNEX 7B- 2

DEPLOYING SPECIAL SERVICE IMPLEMENTATION

SPECIAL SERVICES
CODE CASE
1. BLND Accompanied cabin crew service
2..DEAF Accompanied cabin crew service

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3. MEDA Accompanied cabin crew service

Syringes and over 6 cm hypodemic needles used onboard
4. OXYG and/or STCR

5. PREG Accompanied cabin crew service

6. UMNR Accompanied cabin crew service

7. WCHC Accompanied cabin crew service

ANNEX 7B – 3

MEASURES TO CALCULATE THE NUMBER OF SEATS REQUIRED FOR

INSTALLATION OF OXYGEN BOTTLES

Step 1: Based on indications by the physician in MEDIF II advising of the liters of oxygen
per minute flow rate and on the details of passenger’s itinerary, reservation staff shall

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calculate the number of oxygen bottles required on each flight, following the below
formula:

Number of (liters of oxygen/minute) x (usage time) x 60 minutes) x 120%

oxygen bottles =
(round up) Oxygen volume

Usage time includes flight time, transit time, boarding time (30 minutes) and unboarding
time (30 minutes).

Step 2: Compare the result obtained from step 1 with the table below. The result in step 1
cannot exceed the maximum number of bottles allowed per individual aircraft type.

Table 1
MAXIMUM NUMBER OF OXYGENS CARRIED ON BOARD

IN CABIN
AIRCRAFT TYPE
(number of bottles)
B787 12
A350 18
A330 07
A321 07
ATR72 07

Step 3: Calculate the number of seats required to install the obtained number of oxygen
bottles, referring to the below table:

Table 2
MAXIMUM NUMBER OF OXYGEN BOTTLES ALLOWED TO INSTALL
IN ONE SEAT

AIRCRAFT TYPE NUMBER OF BOTTLES

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B787 02
B777 02
A350 02
A330 02
A321 03
AT7 03

Step 4: Calculate the number of seats required for OXYG passenger:

Number of seats for OXYG = Number of seats used by OXYG passenger +
passenger Number of seats for installation of oxygen bottles

Step 5: Make reservation according the result obtained from step 4.

ANNEX 7 B – 4
MEASURES TO CALCULATE THE NUMBER OF SEATS REQUIRED FOR
INSTALLATION OF STRETCHER
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Step 1: Check the aircraft type operated on requested flight.

Step 2: Obtain the number of seats required for installation of stretcher based on the table
below:
Table 3
NUMBER OF SEATS REQUIRED FOR STRETCHER INSTALLATION ON
VNA’S AIRCRAFTS
Quantity of seats for
Aircraft type
stretcher installation
B787 7
B777 9
A350 9
A330 6
A321 8
AT7 6

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