Appendix
Clasification Society 2024 - Version 9.40
Statutory Documents - IMO Publications and Documents - Circulars - Maritime Safety Committee - MSC.1/Circular.1218 – Guidance on Exchange of Medical Information Between Telemedical Assistance Services (TMAS) Involved in International SAR Operations – (15 December 2006) - Annex - Guidance on Exchange of Medical Information Between Telemedical Assistance Services (TMAS) Involved in International SAR Operations - Appendix

Appendix

IDENTIFICATION OF THE REQUIRING TMAS:
Name: ............................................................................................................................................  
Address: ......................................................................................................................................... Tel: ............................................................
........................................................................................................................................................ Fax: ............................................................
........................................................................................................................................................ Email: ............................................................
                 
CONFIDENTIAL MEDICAL INFORMATION
                 
MEDICAL ASSISTANCE AT SEA
TMAS - TMAS Medical Information Exchange Form
                 
To: TMAS:.........................................................................................................................................................................................
  (via MRCC if necessary: ...................................................................................................................................................................)
Date: ............/........./.........   Time: ..........h........... Physician: Dr....................................................
                 
        PATIENT      
Surname: ............................................................................................................. First Name: ................................................................................
Date of Birth: ............/........./......... Age: .......................................   Sex: M F
Nationality: ........................................................................................................... Occupation on board: ................................................................
                 
      MEDICAL CIRCUMSTANCES      
Illness ..................................................................................................................................................................................
Accident ..................................................................................................................................................................................
Poisoning ..................................................................................................................................................................................
Since: .................................... ..................................................................................................................................................................................
                 
Previous Medical History Ongoing Treatments Care on board before Teleconsultation
....................................................................... ....................................................................... .......................................................................
....................................................................... ....................................................................... .......................................................................
                 
      MEDICAL OBSERVATION      
                 
Pulse: ... ../ min BP: .../...mmHg .............................................................................................................................
BR: ... ../min T: ............... °C .............................................................................................................................
Weight: ......... Kg .............................................................................................................................
Height: ......... m .......
Diagnosis(es) given: ................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
IDENTIFICATION OF THE REQUIRING TMAS:
Name: ............................................................................................................................................      
Address: ......................................................................................................................................... Tel: ............................................................
              Fax: ............................................................
              Email: ............................................................
                   
        MEDICAL INSTRUCTIONS      
                   
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................
                   
        MEDICAL ASSISTANCE REQUIRED      
                   
Medical Decision: Ship diversion to (Port): ...........................................................................................................................................
      Ambulance
      Medical Team: Doctor Nurse Paramedic
    Medical Evacuation
      Medevac Time frame: Immediate Daylight hours
      ...............................................................................................................................................................................
      Medevac Method: Land on Winch/stretcher Winch/Strop
      ...............................................................................................................................................................................
      Medical Team: Doctor Nurse Paramedic
    Air Drop of supplies:
      ...............................................................................................................................................................................
      ...............................................................................................................................................................................
    Quarantine situation
      ...............................................................................................................................................................................
      ...............................................................................................................................................................................
                   
          SHIP        
                   
Ship Name: ............................................................................................................   Call Sign: .......................................................
Type: ......................................................................................................................   Flag: ...............................................................
  Location: .........................................................................................        
  Port of Origin: .................................................................................   Departure/DTG: .............................................
  Destination: ....................................................................................   ETA/DTG: ......................................................
Contact: .......................................................................................................................................................................................................................................
Please send back all the available follow-up information to:
                   
TMAS Name: ................................................................................................................................        
Address: ................................................................................................................   Tel: .................................................................
................................................................................................................................   Fax: ................................................................
................................................................................................................................   Email: .............................................................
Parent topic: Annex - Guidance on Exchange of Medical Information Between Telemedical Assistance Services (TMAS) Involved in International SAR Operations
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