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|  |  |  |  |  |  |  |  | Category |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  | Answer ALL questions-put a cross (x) in \"YES\" or \"NO\" boxes.\u003Cbr>Use BLOCK LETTERS or TYPEWRITER when completing this form. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| A | NAME / INITIALS / TITLE |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | Last name :   ..   First name :   ..   ...   ..Title :   .. Age :   . |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| B | PROPOSED ITINERARY\u003Cbr>(airline (s), flight number (s),\u003Cbr>class (es), date (s), segment (s),\u003Cbr>reservation status of continuous\u003Cbr>air journey) |  |  |  | 1st Flight No. : TG   ... From:   ..…To:   Date:   PNR:  \u003Cbr>2nd Flight No. : TG   ... From:   ..…To:   Date:   PNR:   |  |  |  |  |  |  |  |  |  | Transfer from one flight to another often requires LONGER connecting time (Minimum Connecting Time must be at least two hours. ) |  |\n| C | NATURE OF INCAPACITATION / ILLNESS: MEDICAL CLEARANCE REQUIRED?\u003Cbr>\u003Cbr>\u003Cbr>No\u003Cbr>Yes |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| D | IS STRETCHER NEEDED ON BOARD?(all stretcher cases MUST be escorted. ) |  |  |  |   No   Yes |  |  |  |  |  |  |  |  |  | Request rate if unknown |  |\n| E | INTENDED ESCORT (name, sex, age, professional qualification, segments if different from passenger) |  |  |  | Last name:   First name:   Sex:   Age:   Doctor / Nurse / Paramedic/ Other\u003Cbr>PNR:  \u003Cbr>Last name:   First name:   Sex:   Age:   Doctor / Nurse / Paramedic/ Other\u003Cbr>PNR:   |  |  |  |  |  |  |  |  |  | For blind and/or deaf, state if escorted by trained dog. |  |\n| F | WHEELCHAIR NEEDED?\u003Cbr>Categories are\u003Cbr>*WCHR *WCHS *WCHC Wheelchair Category: |  No  Yes |  |  | Own\u003Cbr>wheelchair |  | Collapsible |  | Power\u003Cbr>driven? |  |  | Battery Type\u003Cbr>(spillable?) |  |  | Wheelchair with spillable batteries are\"restricted articles' and are permitted on passenger aircraft only under certain conditions, which can be obtained from the airlines (s) . In addition, certain countries may impose specific. restrictions. |  |\n|  |  | | WCHR\u003Cbr>WCHS\u003Cbr>WCHC |  | | No\u003Cbr>Yes | | No\u003Cbr>Yes | |  | No\u003Cbr>Yes | | No\u003Cbr>Yes |  |  |  |\n| G | AMBULANCE NEEDED? | \u003Cbr>No\u003Cbr>Yes |  |  | To be arranged by PHYSICIAN AND/OR PATIENT Specify ambulance company contact:\u003Cbr>Specify destination address:\u003Cbr>|  |  |  |  |  |  |  |  |  |  |  |\n| H\u003Cbr>H1\u003Cbr>H2\u003Cbr>H3\u003Cbr>H4 | OTHER GROUND\u003Cbr>ARRANGEMENTS NEEDED\u003Cbr>Arrangement for delivery at airport of DEPARTURE Arrangement for assistance at CONNECTING POINTS Arrangement for meeting at airport of ARRIVAL\u003Cbr>Other requirements or relevant information | \u003Cbr>No\u003Cbr>Yes |  |  | If yes, SPECIFY below and indicate for each item:\u003Cbr>(a) the ARRANGING airline or other organisation,\u003Cbr>(b) at whose EXPENSE, and\u003Cbr>(c) CONTACT addresses/phone numbers where appropriate, or whenever specific persons are designed to meet/assist the passenger. |  |  |  |  |  |  |  |  |  |  |  |\n|  |  | \u003Cbr> No  Yes |  |  |  |  | Specify: |  | |  |  |  |  |  |  |  |\n|  |  | \u003Cbr> No  Yes |  |  |  |  | Specify: |  | |  |  |  |  |  |  |  |\n|  |  | \u003Cbr> No  Yes |  |  |  |  | Specify: |  | |  |  |  |  |  |  |  |\n|  |  | \u003Cbr> No  Yes |  |  |  |  | Specify: |  | |  |  |  |  |  |  |  |\n| I | SPECIAL IN-FLIGHT ARRANGEMENTS NEEDED such as: special meals, special seating, leg-rest, extra seat (s), special equipment, etc.(See Note* at the end of PART 2 overleaf) | \u003Cbr> No  Yes |  |  |  |  | If yes, DESCRIBE and indicate for each item:(a) SEGMENT (s) on which required,\u003Cbr>(b) airline-ARRANGED or arranging third party, and (c) at whose expense.\u003Cbr>Provision of SPECIAL EQUIPMENT such as oxygen etc., always requires completion of PART 2 overleaf.\u003Cbr>|  |  |  |  |  |  |  |  |  |\n| J | DOES PASSENGER HOLD A \"FREQUENT ","cbCairYGwEWNPubb","https://ap.wps.com/l/cbCairYGwEWNPubb","pdf",1099009,"English","# Part 1 - Handling Information\n## Passenger and itinerary details\n## Incapacitation, clearance, and stretcher/escort\n## Wheelchair and ambulance needs\n## Other ground and in-flight arrangements\n## Frequent traveller medical card (FREMEC)\n# Part 2 - Medical Information Form (for attending physician)","[{\"question\":\"Who completes Part 1 of the MEDIF form?\",\"answer\":\"Part 1 is to be completed by the sales office/agent.\"},{\"question\":\"What information does Part 1 collect from the sales office/agent?\",\"answer\":\"It collects passenger identity and proposed itinerary, the nature of incapacitation and whether medical clearance is required, and handling needs such as stretcher, escort, wheelchair category, ambulance, ground arrangements, and special in-flight arrangements.\"},{\"question\":\"What is Part 2 and who completes it?\",\"answer\":\"Part 2 is the medical information section intended for the attending physician to provide confidential answers so airlines’ medical departments can assess travel fitness and issue directives for welfare and comfort.\"}]","MEDIF - Incapacitated Passengers Handling Advice | PDF"]