30 SETTLEMENT FOR ACCIDENTS TO AMERICAN SEAMEN

REPORT OF ILLNESS

Notice. It is extremely important that the following questions be fully answered.
Patient should be questioned regarding details not known to person making report.

Name of Vessel eee Flag
{ Name ween
AQAIESS memoriams remorse sm emerson. mer if rc mas erent rt
Age esr Nationality. Married? Us 8, Citizen Pen
Rating or capacity on Vessel... om «om mis
Wages Per MONth ee mssrimsm mms sm san am simm——
Name and address of nearest relative or friend ei cm po loo

Voyage Number...

{~The Patient

Date and hour illness first TePOTted mms moe seers
TO WHOM FPOTEEA noms rms se msssoss remo et mr sess 53am me ness mr ei
Complaint and statement made by patient. nm

2 —The Illness

Physical signs and/or symptoms...

IPT TT S——————————————
Describe in full all treatment given to patient on board vessel...

etter eb ers rm A 18 me rem rebtas 41 rt Rss 1 ret ret ee tt
By whom was patient treated on board vessel.
Name znd address of attending physician, if anys.

Treatment
on Board
s—and Final
Disposition
of Patient

Was patient able to resume full duties on vessel
Was patient sent to hospital on shore eo
By whom —— efit What POT oe
Name and address of hospital or

eee eee eb ee et rr.
Date and hour on which patient was sent to hospital —.
(f patient was not sent to marine hospital, state reason —

e——————r | ——————————— tert stmt erat srr
Had patient suffered similar illness before joining vessel

ee ta ——- eh eee AA Pe B=