Medical evacuation form




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MEDICAL EVACUATION FORM


To be faxed, or sent to the United Nations Medical Director

Fax No.: (212) 963-4925




PART A: TO BE COMPLETED BY THE MEDICAL OFFICER, THE UNITED NATIONS DISPENSARY PHYSICIAN OR THE UNITED NATIONS EXAMINING PHYSICIAN RECOMMENDING MEDICAL EVACUATION




Duty Station :

     

Country:

     

Name of Evacuee:

     

Date of Birth: (d/m/y)

     

If Evacuee is not the Staff Member, name of Staff Member:

     

Index No.:

     

Agency/Organisation:

     

Diagnosis:

Reasons for recommending medical evacuation (if necessary, attach additional sheet):

     

Is the evacuee travelling alone?  Yes  No

If no, who is accompanying the evacuee?

 Doctor

 Nurse

 Family Member

 Donor

Place of evacuation recommended:

     

Expected duration of medical evacuation:

     

Name of Physician:

     

Date: (d/m/y)

     

Signature:




PART B: TO BE COMPLETED BY THE MEDICAL SERVICES DIVISION UPON RECEIPT OF THE MEDICAL REPORT ISSUED BY THE ATTENDING PHYSICIAN AT THE PLACE OF EVACUATION




Medical report received on:

     

Final Diagnosis:

     

Actual place of evacuation:

     

Departure Date: (d/m/y)

     

Return Date: (d/m/y)

     

Hospitalisation – Admitted on : (d/m/y)

     

Discharged on: (d/m/y)

     

MS.39 (5-00)E




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