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    2018 WSR

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    2ncnz6999m

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    2018 WSR

    Uploaded by

    2ncnz6999m
    24 views1 page

    Original Title

    2018.WSR

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    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
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    24 views1 page

    2018 WSR

    Uploaded by

    2ncnz6999m

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    **** MEDICAL DOCTOR MUST COMPLETE REPORT****

    WORK STATUS REPORT

    US MARITIME CONSULTANTS
    [email protected]

    PHYSICIAN NAME: ________________________________ SPECIALTY: ______________________

    Email address: ______________________________________ Telephone #: ______________________

    PATIENT NAME: __________________________________ DOB: _____________________________

    Diagnosis: ___________________________________________________________________________________

    ____________________________________________________________________________________________

    Treatment: __________________________________________________________________________________

    ___________________________________________________________________________________________
    Follow up date: __________________ Referral to Specialist Yes  No 

    If yes, please provide details: ______________________________________________________________

    Mandatory: Crewmember Medical Discharge Information

    I have examined Mr./Ms. _______________________________________and find it true and correct that as of


    today (date) ______________ the following applies:
    The definition of Maximum Medical Cure is as follows: The accepted legal standard holds that maximum cure is
    achieved when it appears probable that the further treatment will result in no betterment of the seaman’s condition.
    Thus, where it appears that the seaman’s condition is incurable or that future treatment will merely relieve pain and
    suffering but not otherwise improve the seaman’s physical condition, it is proper to declare that the point of
    maximum cure has been achieved.

    Maximum Medical Improvement Yes  No 

    If No, what is the expected length to reach MMI? Days Weeks Months______

    Is this crewmember fit to return to work? Yes  No 

    Is this crewmember fit to travel? Yes  No 

    Restrictions: Yes No  Duration of restrictions: ______________________

    Details of restrictions __________________________________________________________

    Signature of Physician _____________________ Date: _______________


    Upon completion of this report, please email to: [email protected]

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