INCAPACITATEO PASSENGERS HANDLING ADVICE

PART I
HANDLING INFORMATION

PART

To bc

['*AD
A

compLt d
by

pul a c'os! ( x I in 'YES' or 'l,lo' bor.r

ArEsiar All quartidr!
t sc SLOCX LETTERS ot TYPEWRITER wtrn oornflering thi. lorm

SArlS OFFEE'AGENT

NAME/INI'IIALS/NTLE:

hffi
llioht
to arcthef dten roquilot

PROPOSEO ITINEMRY

Transi8r

(eirliru(r), fi ight numbcr(3},

dess(os), dalo(s), EcAmonts(6),
EleMtioo ststus d cdltiru4!

LOf.IGER

MTUBE OF INCAFACNATION:

IS STREICHER NEEDEO ON BOABO?

(all stEtchor csr.! MUST be
BCOrlCd).

INTENOED ESCOffT (mrno, !cx, aCB,

profrsional quliltcatiql 8o9m6nt3
if ditturent from ps$nge4.
It untEined, state TFAy'EL COMPANIOI{'

mnocling

MEorcAL

*"errc"^,r*tto.ot

HEOUIREO? Yer

Ho

NO

NEEDE'? *o [--l ,,

ff
"""

i
2

Anangmnts br
esai8lam al

sP""itY

o"ttimtin

(b9.

with soillabl battoria! 8

'dangerds g@d8' and aro Porminod

pa$ongBr aircaft dY undet erlaill

s)ditiffs which 6 ba obtaimd tDm th
airline(s). In addition, carlain counlri8 may
inrcso lp@ifi c re8tricliff 3
RequBt

raro(s) il

unk|m

addross:
(b)

specific

pscds

ar dsigmted to mVdsi3t th pa$ngar

Specrfy

if

r".

f-l

Spocity

ves

l--l

spocitv

d ARR'\AL
Othar rgquiremontt
or relda'|l

t--l

ves

l-_l

s*",r,

3 Arngrmris lor

mting

8l airport

inbrmtim

ys, DESCRIBE and indite br oach itsm: (a) SEGMENT(S) m which

requkod, (b) airtine-ARRANGED or arranging thkd p8rty, and (c) at whGe
qmnse. P@idm of SPECIAL EOUIPMENI such oxyg6n' ota
always requiros @mplstion ol PART 2 o/orlaf.

SPECTAL IN.FLIGHT

ARMNGEMENTS NEEOED, tuch a3:

spooial mals, 3pecial sasting,

bg.6!t, .nE sst(3), tp.oisl

l--l

OEPARTURE

CO{NECTING POINTS

l--f*

dliwry at sarport

l-l

ves

Wtpdcldc

|
=

at
I ws. SPEC|FY b|ff and inditg lotr 6ach ilom: (a) th ARR/\I\IGING airlim or othr organi$tim,
wfose EXpENSE. and (c) CONfACT addrsser/tlophono numbots wttsrs spprcpriat, or wlp'1ar

ARMNGEMENTS NEEDED

AfEngomnts br

*"

gli

l--l

unkwn.

Tober rengpd by AIRLINE

M I l-t specify ambulare @mparry mtaqti
Yor

OTHSR GROUND

J)
fII

f-T

u,/l

vaa

WhelcMir @rogprY

AMBUTAN.E

Reouest raio if

ffifi ttHo
*ffi" ?'"t''t'"
/
*o
/*"

[-l

wcHR wcHs wcHc

tl

Yo8

For blind s.r,/or

dsat. 6tato if
osooned by lrainod

Categoriet ar3;

*o

CLEAMNCE

time.

oquipmont, etc

(s$ 'Not r" 8t tha

end

mRT 2 ffideaq

tl

OOES PASSENGER HOLD A'FNEOUENT

TMVEI I FR'S MEOICAL CARD (FREMEC)"
\ALIO FOB THIS TRIP?

L
(ls8ued by)

0alid until)

f y6, add belil FREMEC dala to }!Ur r66emtim toquestc

It m (or il addilional data nsdsd by errying aidin6(s)),
fsE pfrysician in attondance complot PAFT 2 hereof.

NE
(Sq)

(ASe)

(Umitatims)
MSSENGEF'S DECI.ARATIOI.I
"r

HEREBvArrrHoBrzE

...........................

6i"*

;;;il;;h;;;;;;i

toprcvid8thailimswiththinb'mationrcqUirodbythGoair|imsmedieldpartm6dsbIttpurpo86cid6terminingflnessb
agr6 to meet such pttysician'3 bes
t1*. pfryeic6rl of his/tb, proc.g*, o,iy J&tiJ"trii"titv in r"p.ct d such inltcrffitim, and

in

mmclis thsrililh'

|t8krt!thar,i|a6gpt6dbrdrrig'8r,@rne},wi||bcsubiocttot'goneratgditid3c..riago^arifsofth6fiorr'n6d8ndthattheri9rdoe3nolas3umearIysp@ia||hbi|
dsding lhoss conditions/ierifh'
|ampr6pared.atfrornrEk.toboara|r@nsoqUem3whichcarriag6byairmayhabrrr\,statdha|thandt'el8assthrrio(itsemp|oy6es,serantsandagonb''ar|iabi|rb'
EUCh

@arsaqu6rco3

IagrstoroimbuGeth6errirupondemand|o'aryspocia|sxpenditureso.costsincdnectjffwithmyrriag6."
(w|EBftodod'bboreedby|tot|rpassongetidatedandsigttdbyhlm|E|o|ffihlsl|p|bttst')
Place:

Oats:

Fassengr's Signaturo:

n
PART

MEDICAL INFORMATION SHEET

{for olficial use only)

fhe form must be relurned tol

The PHYSICIAN ATTENDING the incapacitared passenger is requesred ro ANSWER ALL

OUESTIONS. {Enter a cross x in lhe appropriale "yes or "no' boxes, andlor grve
precise concise answers).

To bG cofrplatad

MEDAOl

This form is intended to provide CONFIDENTIAL information. lo enable the airlines

MEOICAL Departments to assess rhe fitness of rhe passenger to Iravel as indicated an
PART t hereof. ll th passenger is acceplable. this informalion wil! permil the iss!ance
of the necessary directives designed to provide for (he passenger's welfare and comlori.

OF THE FOFM IN SLOCK LETTERS OR BY

COMPLETINJG
APPRECIATEO,

ATTNDING PHYSICIAN
Airlines
Rel. Code

PART

WILL

BE

'YPEWRITER

lCarr;er's Desianated Otlice)

PA-TIENT S NAME, INI

TIAL{Si, SEX, AGE :

AITENDING PHYSICIAN

Name & Address

MEDAO2
Telephone Contacl

Business

MEDICAL OATA:

'DIAGNOSIS in derails
(including viral signs)

MEDAO3

- Dav/monlh/vear ol fi.st svmolomsl

I o"re

lor the rrio

MEOAO4

PFOGNOSiS

MEOAO5

Contdgious ANO commun,

cdbre drseaser

*o

MEDAO6

Would lha phytrcll lndlor m6nttl condrlron ol th6 pationl

ba likoly lo ctu3o distrGs or discomfod to olhor psssqnggrs?

No

MEDAOT

Can palient lse normal aircratl seal

with seatback Flaced in rhe UPRIGiIT
position when so requiredT

MEDAO8

Can palienl take care of his own needs

on board UNASSISTEO' {including meals.
visit ro ioilet etc )?

L-

MEDAlO

Does parienr need

"

*o

[]

soecirv

f_l

No

[--l

No

l--l

Yesl I

[-_l

Lrrfes _

o"' |

Minure

conrtnuous) v"sl--l
*. Fi

(a) on lhe GFoUND while al rhe ai'po((sl:

any

lff3$,l::l;J*'o

l--l

*"

dal aPparalus such as

resprraror. Incuoaror.

MDAI2

ves

v". [--l
N. T-l
,
.
-::you: |
proposed
It not. type
"" of
". escon
"-* """-, by

slate rale of flow)

MEOAl

Soecifv

ll nOt type ol help needed:

vouT

Does palient need OXYGEN

equipmenl in fhghl? (ll yes.

f]

v".

lf ro be scoRTEo. is rhe aransdment_

l/E hereot salisfaclorv

lor

l---l

ves

'"r

proposed in PART

MEOAO9

or aiagnor"

{b) on board of lhe

v""

l--l

specrv

"",

f]]

specry

AIRCRAFT:

r.ro

l--l

(a) during long layover or nightstop al CONNECTING POINT:

.Ooes patienl need

HosprrALtsAloN?

MEDA13

*o

(tf yes. indicate

arrangemenls made
made. indicale

'NC ACTTON

MEOAl

(b)

TAKN.)

f]

infornation in the

Ij;:?:1.'*::1,
and comto(able

MEDAl 5

i--_l

Acr,on

l-_l

Acrion

upon arrival at OESTINATIONI

". l--l
. Other rema.ks ot

v"r

r""

I
I
I

ro""

l--l

spec,ry i' anv..

transDo(ation:
Other arrangements
made by the axending

MDA 1 6

physician:

NOTE

Dare

(r):

Cabin attendants a.e NOT authorized to give special assislance lo

particular passengrs, lo the delramenl of lheir service to olher
passengers. - Addilionally. they are lrained only in FIRST AID and are NOT
PERMITTED lo administer any injeclion. or to give medicalton

F;

IMPORTANT: FEES, lF ANY, RELEVANT TO THE PROVISION OF THE ASOVE

INFORMATION AND FOR CARRIEB'PROVIOED SPECIAL EOIJIPMFNT
I") ARE TO BE PAID AY TH PASSENGER CONCERNED.

}o**"n,^'.""*r*

p7O/So Sl