GRIPSHOLM SHIPPING S.A.

SHIP MANAGEMENT

SICK JOURNAL REPORT

Vessel :

Date of Report :

Full name :

_______________________________________________________________________________

Position :

_______________________________________________________________________________

Born : (place/date)

_______________________________________________________________________________

Nationality :

_______________________________________________________________________________

Home Address :

_______________________________________________________________________________
_______________________________________________________________________________

Medical History : (As per ships record)

Special Information

________________________________________________
Signature of Master or Deputy
Case referred to :

_______________________________________________________________________________

Mail bills to :

_______________________________________________________________________________
Vessels agent and address

Doctor / Hospital

Physicians diagnosis & services rendered :

Is patient fit for duty ?

If not, give information as to recommended treatment

When is he expected to recover ?

Date of examination :

1 Copy - GRIPSHOLM SHIPPING S.A. ; 1 Copy - Ships File No. 9

1 Copy - Doctor ; 1 Copy - Patient;

_______________________________________________
Signature of Physician

GRIP FORM - 07