ADDITIONAL INFORMATION

Any additional information you deem

important for inclusion in the Medical
Evacuation Response Plan?

CLIENT’S SIGNATURE

Requested by: Position: Date:

Thank you for taking the time to fill out this questionnaire.

Attachment Reminder:
1. Please attach a JPEG picture of the vehicle available to the traveling party.
2. Please attach a WORD document of the onboard medical equipment list (for the guidance
of the International SOS coordinator doctor).

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Medical Evacuation Response Plan Questionnaire

CONFIDENTIAL
7
 MEDICAL EVACUATION
RESPONSE PLAN (MERP)
QUESTIONNAIR RE (Part 2)
To be completed by the International SOS Account Manager (Mandatory)

CONTRACT DETAILS
Project Membership Number for the Site
- WINIS ID
- Any Corporate Membership
- If YES, specify Membership Number
- If YES, specify WINIS ID

INTERNATIONAL SOS ACCOUNT MANAGER

PAM (Primary Account Manager)

- Name
- Location
- Direct Telephone Number
- Mobile Phone Number
- E-mail Address
- Facsimile Number
- After Hours Telephone Number

INTERNATIONAL SOS MEDICAL STAFFING (IF APPLICABLE)

1. Position 1
- Full Name and Job Title (MD, RN,
EMTP…)
- Country of Origin
- Please include a copy of the staff’s
Curriculum Vitae / Résumé
2. Position 2
- Full Name and Job Title (MD, RN,
EMTP…)
- Country of Origin
- Please include a copy of the staff’s
Curriculum Vitae / Résumé

PAM’S SIGNATURE

Requested by: Position: Date:

Medical Evacuation Response Plan Questionnaire

CONFIDENTIAL
8