Appendix: 03

MEDEVAC REQUEST FORM

PERSONAL INFORMATION

International UN Staff EMERGENCY:

Locally recruited staff NON EMERGENCY:
Staff Officer/Milobs
Contractor
Contingent Member/Troop

Name (Last, first, middle)

Age

UN ID No

Rank/ Title

Duty Station

Nationality
Due to:
Specify :
Illness
Accident
Injury
Other

MEDEVAC REQUESTED TO (destination):

DATE ON WHICH MEDEVAC MUST TAKE PLACE:
ACCOMPANYING MEDICAL PERSONNEL NECESSARY: Yes: No: 
Specify: Name: UNID:
FROM:
Location/Hospital:
Telephone and Fax Number:
Name of Contact Person:

Signature: Date:

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 Appendix: 03

Patient UN ID No :

The following additional medical information is confidential and should be treated as such.

Present hospitalization:
From: Until:
Hospital:
Current Diagnosis:

Treatment (previous and current):

Present health-status:

Special Treatment and Equipment Required During Transport:

Other Comments:

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 Appendix: 03

FROM:
Location/Hospital:
Telephone and Fax Number:
Name of Contact Person:

Signature: Date:

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