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NOsalAtAN PENGKffAil s,TnntAN pASrR EMAS,K&PASTR pUTtH,


&ZoG,PA,SIR GUDANG,TOHOR

TEL NO: sZ- 27!2988. FtX NO: oZ - 2fu39CI

X-BAY E(AMTNATION

ktvwe rrorxwy

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Qu7Y

AGE

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SH

=. l^yBt-E

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*RAY NO:

r e ()cT 2018

DATE

GTEST X.fiAY ETPGBT


THE ITIi{GS AHE CLEA,*.

T}IE Hf.AfiT

l
XS

}IORil{A:. IN SEE At{D CONffIG{*ATiCili.

T}'AR= IS NO SKEIgTfl GA SOFT T?SSl'fl A=NoBMATJTES DETECTED.

&.

Seae*wetA

MMC 33{i(N
TIONAT HEALTH DOCTOR
(JKKP HQ/1 3i DOCl00/300)
APPROVED MARINE DOCTOR (PP258}
UFDICAT REY]FW OFFICER (MRO'

POLIKLINIK ROZIKIN
E,
_ No. 52,lalan pengkahn
Tamrn Pasir
paeir pEtifu

Emas, iig.
81700 Prstr 6udang, Johor.
lb& 0?.971 tgtt / Fax: 0?-2Zl lsgg

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POTIKLINIK ROZIKTN
No:52,Jalaa Pengkafua 5,Taaan pasir E'.masJ<g.pasir.pr:til:,g1700pasir
GudaagJohor
Tel Nol 07-2?12988 Fq No;01.-2711390

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ALAMA:I : ..........:...

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r*E

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BERKA}rtrRI/BUIA}IG

ulrfs!(DESiOr,ffi?umJA
Adakah aaa ,nenSadryi peryakit-peaSakit seperti berikgt

YA

TIDAK

a) Epiispsy (savra), kelainan otak, sakitjiwa, lumpuh

b) Sakitjaat@g kslainmjaatuag damh #*ggr, krmgdaral


c) Bcuk kaing (TB), asthma, sakitparu

- paru, tekak

Cstdk ulser,batuhempedu, hmia,kelainim salurm usus

e) Kelajnan kenciag, alat kel"ror'n , sa&b,buah pinggaag

&Ecing

uaauiq, gout, sakit

g)

Affi.s,

sa&it sendi, sakit tujang,

kalejar, Smoid

;,
_/.,

h) Kslaisan frata ,1etingr, hiihmg,

i)

Kecacaaa aaggota dan laia - lain

j)

Kanser, ketirmbuhaa datr lai! - laia

Saya aengaka bafuwa keterangan di stas adalan bena.

Tmdaaso:

II

oCT

2016

i.

POLIKLINIK

ROZTKTN Gr:daogJohor
:

hxtih,S 1?00fasir
No:52Jalao Peagkalaa S,Tamm Pasir Emas,Kgle
Tel No:'07'nl,2g$}Fax No: A72711390

-NORMAL

NoRrfim,-*,:TlrX

2)aceadamGuk&sismsnsraf(trreasokrsllex&kmdina$|
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r!
3) relinsa,hiduns,tekakt""'&T*$q,VAi-

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i,OLIKLINIK ROZIKIT'S'

' No.52,Jalan Pengkalen


Taman Pasit Emas, Kg. P*e'ir Fsti'h'
81700 Pastr 6udtag, Johor'
t1: 6?-3?l ?988 / Fax: 0?-271 11q&

1-

APPENDIX C: SAMPLS OF FITNSSS TO WORK C=eTlFlCATlON FORM (M=D=X 002)

Fitness to Work Certificate

lype

ot Health Assessment

Pre-employment

fl

r,"-o,rcement

Overseas Posting

Routine

.roo-.n".in.

Others

lnrproyee s nan,c.

&g.qtJ

OgaJ

..W

rr
-.Ir -$Pr-1

(please tick onl):'


This is to crrtify that I have examined the above named person and found hirnl her to be

Fit to work
Fit to work with restristion
Unfit to work

Remarks/ Restriction:

\,'\

Daie:

I g ()cI 2010

ROZIKI;
?OI/IKLINI$
52' Ialan PengkallB
No'

euesamff
: tt
For Company use only.

Ernployee's fitness to work status


Health Adviser's comments:

Health Adviser Signature/ Name


44

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