MEDICAL REPORT FORM Day _____________ Date ____________ Time ____________ To: _________________________________________________________________________________________________________ Dear Sir, We would kindly request you to give necessary treatment to our following employee who had met with an accident and provide us with your diagnosis. Name of injured __________________________________________________________ Age ( ) years. Occupation __________________________________________________________ M.B. No. _______________________________ Date of Accident ____________________________________________ Time of Accident __________________________________ Place of Accident (Project Name) _______________________________ Location _________________________________________ Nature of Accident ____________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ First Aider Name: ________________________________ SE Manager/Incharge: ________________________________ Signature: ________________________________ Signature: ________________________________ (If Medical Certificate is attached, this portion is not required.) MEDICAL REPORT Nature and extent of Accident / Injury____________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Fit for duty___________________________________________________________________________________________________ Unfit for duty_________________________________________________________________________________________________ Remarks_____________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Signature of Medical Officer Date _______________

1. ARABTEC CONSTRUCTION (LLC)
Page 1 of 1 Form # HSEQ – MRF (Rev 3 - 2023)
MEDICAL REPORT FORM
Day _____________
Date ____________
Time ____________
To: _________________________________________________________________________________________________________
Dear Sir,
We would kindly request you to give necessary treatment to our following employee who had met with an accident and provide
us with your diagnosis.
Name of injured __________________________________________________________ Age ( ) years.
Occupation __________________________________________________________ M.B. No. _______________________________
Date of Accident ____________________________________________ Time of Accident __________________________________
Place of Accident (Project Name) _______________________________ Location _________________________________________
Nature of Accident ____________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
First Aider Name: ________________________________ SE Manager/Incharge: ________________________________
Signature: ________________________________ Signature: ________________________________
(If Medical Certificate is attached, this portion is not required.)
MEDICAL REPORT
Nature and extent of Accident / Injury____________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Fit for duty___________________________________________________________________________________________________
Unfit for duty_________________________________________________________________________________________________
Remarks_____________________________________________________________________________________________________
____________________________________________________________________________________________________________
Signature of Medical Officer Date _______________