In-flight First Aid Incident / Medical Report

In-Flight First Aid Incident / Medical Report
A/C Registration*
Flight Number*
Sector*
Date

DayMonthYear
Date
Time*

Hour Minutes
Description of the Kit
Emergency Equipment Location
Kit Serial Number
Passenger Name
Age
Gender
Nationality
Passport Number
In-flight Illness Management

Select from below: Illness Management and Medicine Administered
Allergy
Bleeding
Burns
Cardiac Arrest
Childbirth / Delivery
Choking
Diarrhea
Difficulty of Breathing
Ear Problem
Eye Problem
Dizziness / Fainting
Fever / High Temperature
Foreign Body
Headache
Chest Pain / Angina / Heart Attack
Hyperventilation
Body Injury
Arms / Legs Injury
Loss of Consciousness
Mental Disturbance
Nose Problem
Pain
Panic Attack
Seizure
Stroke
Vomiting
Others
FAK Medicine
EMK Medicine
Diagnosis (If Known)
Illness Management Done
Results*
Doctors Comments/Recommendations
Doctor's Name
License Number
Contact Details
SCCM Name*
SCCM Comments
Signature

Clear
Destination
Ground Medical Assistance Required?
IN CASE OF EMERGENCY LANDING OR FLIGHT DIVERSION
SCCM Name*
SCCM Staff Number*
SCCM Signature

Clear
PIC Name
PIC Staff Number*
Yellow Security Seal No. 1
Yellow Security Seal No.2
Red Security Seal Number: #1
Red Security Seal Number: #2
Should be Empty:

In-Flight First Aid Incident / Medical Report