ILLNESS AND INJURY REPORT

Patient Information Name: YAM BAHADUR BK Age: 34 Nationality: NEPALI Area of Assignment: CCA Position: MASON Company: QCON

JBOG Recovery Project

Reported to GV Camp Clinic: 24-08-2012 16:45 ROOM NO: C5 41 FF3 MOBILE NUMBER: 70176043

Section A. To be filled by the Doctor:

CHIEF COMPLAINT: Cough x 10 days Sick Leave: (Pls. tick) BP - 121/78 T - 36.4 P - 81 RR - 17 (-) colds (+) sorethroat productive cough went to GV clinic 2x, not relieved by meds given Yes If yes, no. of days: No

16:55 - to al madinah QRC/Fluor nurse informed 17:20 - back at GV, no meds given, to come back at al madinah tomorrow QRC/Fluor nurse informed 25-08-2012 8:05 - come back with meds 1. Bromhexine 4mg/5ml syrup 2. Paracetamol 500mg 1 tab q 6hrs PRN 3. Cirrus tablet 1 tab BID 4. Azithromycin 250mg 2caps OD 8:10 - 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: 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.