ILLNESS AND INJURY REPORT

Patient Information Name: ANTONETTO REYES Age: 38 Nationality: FILIPINO Area of Assignment: LAYDOWN Section A. To be filled by the Doctor: Position: CIVIL FOREMAN Company: QCON BADGE NO: JBOG-80243

JBOG Recovery Project

Incident 00/08/2012 Time of Incident: 0000 HOURS Reported to GV Camp Clinic: 28/08/2012 at 18:35 Hrs. ROOM NO: C 3 14 GF 2 MOBILE NUMBER: 33809548

CHIEF COMPLAINT: ABDOMINAL PAIN - SUPRAPUBIC AREA SINCE THIS AFTERNOON Sick Leave: (Pls. tick) > VS: BP: 111/75 PR: 83 T: 36 (-) dysuria (+) bowel movement with blood tinged stool - 1 episode (-) nausea/vomiting Yes If yes, no. of days: No

> Sent to RLMC/ALMADINA for further management >QRC/FLUOR NURSE INFORMED 20:25:Cameback to GV MAC Home meds 1. Hyoscine N Butyl Bromide 1 tab TID prn 2. Flagyl 1 tab TID >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: NIKKO ANDREW B. PIGTAIN - 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.