PART 1 MEDIF TC-GO-006

To be completed STANDARD MEDICAL INFORMATION FORM FOR AIR TRAVEL Page 1 of 3

by Answer ALL questions – Put a cross (x) in “Yes” or “No” boxes
SALES OFFICE/ AGENT Use BLOC LETTERS or TYPEWRITER when completing this form
A NAME/ INITIALS/ TITLE

PROPOSED ITINERARY
Transfer form one flight to another often
B (airline(s), flight number(s), class (es), date(s), segment(s),
require LONGER connecting time
reservation status or continuous air journey)

MEDICAL No ☐
C NATURE OF INCAPACITATION CLEARENCE
REQUIRED? Yes ☐
IS STRETCHER NEEDED ON BOARD?
D (all stretcher cases MUST be assorted?) No ☐ Yes ☐ Request rate if unknown

INTENDED ESCORT (Name sex, age, professional

For blind and/or deal, state if
E qualification, segments if different from passenger) if
escorted by trained dog
untrained state “TRAVEL COMPANION”

No ☐ Wheelchairs with spillable batteries are

OWN Power Battery Type “restricted articles and are permitted on
WHEEL CHAIR NEEDED Collapsible
Wheelchair driven? (spillable?) passenger aircraft only under certain
conditions; which can be obtained from
Categories are Yes ☐
F the airline(s), In addition, certain
WCHR WCHS WCHS
No ☐ No ☐ No ☐ No ☐ countries may impose specific
Yes ☐ Yes ☐ Yes ☐ Yes ☐ restriction.
Wheelchair Category

G AMBULANCE NEEDED? To be arranged by Air Tanzania Company Limited

No ☐
Request
Yes ☐ No ☐ Specify Ambul Company contact
rate(s) if
unknown
Yes ☐ Specify destination address

H OTHER GROUND No ☐ If yes SPECIFY below and indicate for each item (a) the ARRANGING airline or other organization (b) at whose EXPENSE and (s) CONTACT
ARRANGEMENTS NEEDED addresses/ phones where appropriate or whenever specific persons are designated to meet/ assist the passenger.
Yes ☐

1 Arrangements for delivery at No ☐ Yes ☐ Specify

airport of DEPARTURE

2 Arrangements for assistance at No ☐ Yes ☐ Specify

CONNECTING POINTS

3 Arrangements for meeting at No ☐ Yes ☐ Specify

airport of ARRIVAL

4 Other requirements of relevant No ☐ Yes ☐ Specify

information

K SPECIAL IN-FLIGHT ARRANGEMENTS If yes DESCRIBE and indicate for each item (a) SEGMENT (s) on which required (b) airline ARRANGED or arranging
NEEDED such as special meals, special seating, third party, and (c) at whose expense. Provision of SPECIAL EQUIPMENT, such as oxygen etc., always requires
leg-rest extra seat(s), special equipment, etc. No ☐ Yes ☐ completion of PART 2 overleaf.

(see Note** at the end of PART 2 overleaf)

L DOES PASSENGER HOLD A FREQUENT If yes add below FREMEC date to your reservation request, if no (or additional data needed by carrying airline(s),
TRAVELLER’S MEDICAL CARGO VALID FOR No ☐ Yes ☐ have physician in attendance complete PART 2 hereof
THIS TRIP? (FREMEC)

(FREMEC number) (Issued by) (Valid unitl) (Gender) (Age) (Incapacitation)

(Incapacitation count.) (Limitations)

PASSENGER’S DECLARATION

*I HEREBY AUTHORIZE (name of nominated physician)

to provide the Air Tanzania Company Limited with the information required by the Airline Medical departments for the purpose determining my ftness for carriage by air in consideration thereof I hereby relieve
that physician of his/her professional duty of confidentiality in respect of such information and agree to meet such physician’s fees in connection therewith.

I take note that, if accepted for carriage, my journey will be subject to the general conditions of carriage/ tariff of the carriage concerned and the carrier does not assume any special liability exceeding those
conditions/ tariffs.

I am prepared, at my own risk, to bear any consequences which carriage by air may have for my state of health and releae the carrier, its employees, servants and agents from any liability for such consequences.

I agree to reimburse the carrier upon demand for any special expenditures or costs in connection with my carriage
(Where needed, to be read by/to the passenger, dated and signed by him/her or on his/her behalf)
 (Text may be modified by Air Tanzania Company Limited issuing the MEDIF, to comply with local law)
PART MEDIF MEDICAL INFORMATION SHEET
(for Official Use only)
2
Page 2 of 3
This form is intended to provide CONFIDENTIAL information to enable the airline MEDICAL
Departments to assess the fitness of the passenger to travel as indicated in PART 1 hereof.
If the passenger is acceptable this information will permit the issuance of the necessary The form must be returned to
directives designated to provide for the passenger’s welfare and comfort.
To be completed
by
The PHYSICIAN ATTENDING the incapacitated passenger is requested to ANSWER ALL
ATTENDING
QUESTIONS (Enter a cross “X” in the appropriated “yes” or “no” boxes. And/or give precise
PHYSICIAN
answers)
(Carrier’s Designated Office)
COMPLETING THIS FORM IN BLOCK LETTERS OR BY TYPEWRITER WILL BE
APPRECIATED
Airline
PATIENT’S NAME
Ref: Code
INITIAL(S), GENDER, AGE
MEDA 01
ATTENDING PHYSICIAN
MEDA 02 Name & Address
Telephone Contact Business Home
MEDICAL DATA
DIAGNOSIS in detail (including vital
MEDA 03 sign)
Day/ month, year of first symptom Date of diagnosis

MEDA 04 PROGNOSIS for the trip

MEDA 05 Contagious AND communicable disesase? No ☐ Yes ☐ Specify

Is patient in any way OFFENSIVE to other passengers? (smell
MEDA 06 No ☐ Yes ☐ Specify
appearance conduct)
Can patient use normal aircraft seat with seatback placed in the UPRIGHT position when so
MEDA 07 No ☐ Yes ☐
required?
Can patient take care of his own needs on board UNASSISTED*
No ☐ Yes ☐
(Including meal, visit to toilets etc.)?
MEDA 08
If not type of help
needed
If to be ESCORTED is the arrangement proposed in PART 1/E hereof
satisfactory for you? No ☐ Yes ☐
MEDA 09
If not type of help
needed
Litres
MEDA 10 Does patient need OXYGEN** equipment in flight? (If yes state of flow) No ☐ Yes ☐ No ☐
Per Continuous
minutes Yes ☐
(b) on the GROUND while at the
MEDA 11
airport(s)
Does patient need any MEDICATION* other than self- No ☐ Yes ☐ Specify
administered and/or the use of special apparatus such as
MEDA 12 respirator, incubator etc**? (b) on board of the AIRCRAFT
No ☐ Yes ☐ Specify
(a) during long layover or nightstop at
CONNECTING POINTS on route
MEDA 13
Does patient need HOSPITALISATION? (If yes, indicate No ☐ Yes ☐ Action
arrangements made or, if none were mad, indicate “NO
ACTION TAKEN”) (b) upon arrival at DESTINATION
MEDA 14
No ☐ Yes ☐ Action
Other remarks or information in the interest of
MEDA 15 your patient smooth and comfortable Specify if any**
None
transportation

MEDA 16 Other arrangement made by the attending physician.

Cabin attendants are NOT authorized to give special

NOTE(*): assistance to particular passengers, to the detriment of IMPORTANT
FEES IF ANY RELEVANT TO THE PROVISION OF THE ABOVE
their service to other passengers – Additionally, they
INFORMATION FOR CARRIER PROVIDED SPECIAL EQUIPMENT (**)
are trained only in FIRST AID and NOT PERMITTED
ARE TO BE PAID BY THE PASSENGER CONCERNED
TO ADMINISTER any injection, or to give medication.

Date Place: Attending Physician Signature:

 PART
3 NOTES FOR THE GUIDANCE OF MEDICAL PRACTITIONERS AND PASSENGERS
Page 3 of 3

The Principal factors to be considered when assessing a patient's fitness for air travel are:

 Reduced atmospheric pressure (Cabin air pressure changes greatly during 15-30 minutes after takeoff and before landing and gas expansion and
contraction can cause pain and pressure effects)
 Reduction in oxygen tension. (The cabin is at a pressure equivalent to an altitude of 6,000 to 8,000 feet and oxygen partial pressure is approximately
20% less than on the ground).

Any medical condition which would render a passenger unable to complete the flight safely, without requiring extraordinary medical assistance during the flight
is considered unacceptable for air travel.

Conditions usually considered unacceptable for air travel (Although these are suggested limiting factors, each individual case must be considered on its
merits and is dependent on whether or not the passenger is accompanied by a professional escort)

 Anaemia of severe degree.

 Severe cases of Otitis Media and Sinusitis.
 Acute, Contagious or Communicable Disease.
 Those suffering from Congestive Cardiac Failure or other cyanotic conditions not fully controlled.
 Uncomplicated Myocardial Infarction within 2 weeks of onset complicated Ml within 6 weeks of onset.
 Those suffering from severe respiratory disease or recent pneumothorax.
 Those with GI lesions which may cause hematemesis, melaena or intestinal obstruction. Post-operative cases:
a) Within 10 days of simple abdominal operations.
b) Within 21 days of chest or invasive eye surgery (not laser).
 Fractures of the Mandible with fixed wiring of the jaw (unless medically) escorted.
 Unstable Mental illness without escort and suitable medication for the journey.
 Uncontrolled seizures unless medically escorted,
 Uncomplicated single Pregnancies beyond the end of the 36th week or multiple pregnancies beyond end of the 32nd week.
 Infants within 7 days of birth.
 Introduction of air to body cavities for diagnostic or therapeutic purposes within 7 days.

Notes on other Specific items

Allergies: Simple requests for a special meal do not require completion of this form. If your patient has a life threatening food allergy that may require treatment
in-flight, particularly if they react to the presence of traces of food in the air, this form should be completed. Note; Air Tanzania cannot guarantee peanut free
meals.

Asthma: Medication must be carried in cabin baggage. Nebulisers require their own power source. Spacer devices used with an inhaler are an effective on-
board alternative.

Fractures: All new long bone fractures and full leg casts (cast must be at least 48hrs old) require a medical certificate. Plasters should be split for fresh injuries
(48hrs or less), which could swell inside the cast on a long flight. Extra legroom for leg elevation is not possible in economy class; however, an aisle seat can be
reserved. Please state whether the injury is left or right.

Lung or Heart Disease: Cardiopulmonary disease which causes dyspnoea on walking more than 100111 on the flat, or has required oxygen in hospital or at
home (or in-flight previously) may require supplementary oxygen. The aircraft oxygen is for emergency use only. Serious cardiopulmonary cases as well as
those requesting continuous oxygen, stretcher, or incubator should enclose a recent detailed medical report with the medical certificate. (A copy of a specialist
or hospital referral would generally be sufficient).

Physical Disabilities: There is no need for this form if you simply require a wheelchair as far as the aircraft door; the travel agent can indicate this on the
reservation if you wish. Note: Civil Aviation Rules require all passengers to be able to use the aircraft seat with the seat-back in the upright position.

Special Meals: Special diets for religious or other medical reasons can be ordered direct from your travel agent without using this form. If you have a food
allergy, please see the section on "allergies" above.

Terminal Illness: Passengers in the advanced stages of terminal illness will normally require a medical or nursing escort.

In-flight care: AIR TANZANIA does not provide nursing attendants for invalid passengers. Cabin crew are trained in First Aid only.

Escorts: should ensure that they have all appropriate items for the proper care of their patient, and are responsible for attending to all aspects of their patient's
bodily needs. Due to food handling regulations, Cabin Staff cannot assist with these needs.

Processing MEDTFs

The MED IF should be completed based on passenger's (patient's) condition within one month from the date of commencement of air travel and submitted at
least 48 hours before travel is due to commence. Please be advised that Air Tanzania Medical Services may request further information or clarification prior to
approval of the MED IF. AIR TANZANIA must be notified immediately of any change in the patient's condition PRIOR to travel.