Doc. no.

FORM-COR-SEC-009-E

FORM
Rev. 02 Date 15/11/2016

SECURITY AND HEALTH PRE-TRAVEL SELF-INDUCTION

Page 1 of 1
ACKNOWLEDGEMENT SHEET

Ref. Doc. OPR-COR-SEC-004-E

SECURITY AND HEALTH PRE-TRAVEL SELF-INDUCTION

ACKNOWLEDGEMENT SHEET

Please complete the following form and return it immediately to the officer in charge of your
mobilization by email.

By the present I, _____________________________________________ , _____________________

(Full Name) (Date of Birth)

hereby certify that I have received, read and fully understood Security and Health information issued
by Saipem SECUR Department and Saipem SMEL Department related to the destination:

✔ OFF-SHORE
Portugal
ON-SHORE: _________________________________________________

Moreover, I shall not disclose or communicate the information contained therein to third parties.

Material received:

(tick the box below for each document received)

✔ Security Vademecum

• Security information and the risks that exist in the given country as well as general
security awareness advice and rules of behavior that personnel should follow to help
mitigate those risks.

✔ Health Country Presentation

• Document issued following the International Guidelines and the Epidemiological Alerts
and the institutional Travel Medicine organizations, containing country-specific health
related information and instruction with the aim to protecting travelers’ health and
preventing illness.

Date _____________________ Employee’s signature: ___________________________________

……………………………………………………………………………………………………………………….

To be filled by the company

Company Badge Number of the employee: