UNIX LINE PTE LTD VESSEL MANAGEMENT MANUAL

APPROVED BY: MD

CREW MEDICAL FORM

ORIGINAL TO MANAGERS
1ST COPY TO DOCTOR
ND
2 COPY TO CREW MEMBER
3RD COPY TO SHIPS FILE

PORT: DATE:
Dear Sir,
THE BEARER OF THIS LETTER MR/ MS

WHO SERVES AS ON MT

COMPLAINS OF

KINDLY EXAMINE HIM AND LET US HAVE YOUR REPORT BELOW.

Yours Faithfully
MASTER
MEDICAL REPORT
I HAVE EXAMINED MR / Ms

DIAGNOSIS:

* MEDICATION GIVEN YES / NO

* HOSPITALISATION YES / NO
* REPATRIATION YES / NO
REMARKS:

FIT FOR HIS SERVICE * YES / NO (FOR ABOUT DAYS)

NOTES:

(PLACE AND DATE) (SIGNATURE & NAME OF DOCTOR)

NOTE TO THE DOCTOR: THIS FORM IS TO BE COMPLETED. THE ORIGINAL TO BE RETURNED TO THE VESSEL.

*Strike whichever not applicable

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