ILLNESS AND INJURY REPORT

Patient Information Name: Dilip Kumar Singh Age: 30 Nationality: Indian Area of Assignment: CCA Section A. To be filled by the Doctor: Position: FABRICATOR Company: QCON BADGE NO: JBOG-81999

JBOG Recovery Project

Incident 00/06/2012 Time of Incident: 0000 HOURS Reported to GV Camp Clinic: 25/08/2012 at 12:45 Hrs. ROOM NO: C5/39 GF2-6 MOBILE NUMBER: 70124526

CHIEF COMPLAINT: HEMORRHOIDS FOR 15 DAYS Sick Leave: (Pls. tick) > VS: BP: 113/70 PR: 80 T: 36.5 > (+) pain > (-) blood in stool Yes If yes, no. of days: No

12:50> Sent to RLMC/ALMADINA for further management >QRC/FLUOR NURSE/CAMP MANAGEMENT informed
26-812b@ 10:45 Cameback to GV MAC

1. Cloxacillin 500mg 1 cap q8 2. Ibuprofen 400mg 1 tab TID >QRC/ FLUOR NURSE/ CAMP MANAGEMENT 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: DANTE V. AUSTERO - 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.