BORANG PEMERIKSAAN PERUBATAN Tarikh Pemeriksaan :

Examination Date
Medical Examination Form
Tandatangan Doctor :
Doctor's Signature
Page: 1/2

Cop Klinik :
ALLOWED FOR CANCELLATION/ REFUND Clinic's Stamp

BEFORE 10/03/2020
Kod Perkerja: W6EG049081
Worker's Code
Name Pekerja : GOHAR AYUB KHAN No. Pasport : BZ4108973
Worker's Name Passport No.
Jantina : MALE Negara Asal : PAKISTAN
Gender Country of Origin
Tarikh Lahir : 26-12-1997 Tarikh Pendaftaran : 10-02-2020
Date of Birth Date of Registration
Telefon Majikan : * Majikan : MAHASUTRA KAPITAL SDN BHD
Employer Contact No. Employer
No. Telefon Doktor : 067990311 No. Telefon X-Ray : 06-7991558
Doctor Telephone No. X-Ray Telephone No.
Sah Sehingga : 10/03/2020 Kod Majikan : E2EM046164
Valid Until Employer's Code :

Tarikh Pemeriksaan :
Examination Date
Kod Doctor : D76H000011 Kod Pekerja : W6EG049081 Jantina : MALE
Doctor's Code Worker's Code Gender
Nama Doktor : HARIANTI BINTI HUSAIN No. Pasport : BZ4108973
Doctor's Name Passport No.
Nama Klinik KLINIK AL-RAUDHAH (X-RAY) Nama Pekerja : GOHAR AYUB KHAN
& Alamat : NO. 2, VILLAGE @ ENSTEK 71760 BANDAR Worker's Name
Clinic's Name ENSTEK NEGERI SEMBILAN Sah Sehingga : 10/03/2020
& Address Valid Until

No. Telefon : 067990311 No. Telefon Majikan :* Tandatangan Doktor : Cop Klinik :
Telephone No. Employer Contact No. Doctor's Signature Clinic's Stamp

Nama Pekerja : GOHAR AYUB KHAN

Worker's Name :GOHAR AYUB KHAN

Worker's Code : W6EG049081
Trans ID : 20200210966024
Worker's Name
Kod Doctor : D76H000011 No. Pasport : BZ4108973
Doctor's Code Passport No.
Kod Makmal : L56Q000001 Kod Pekerja : W6EG049081 Jantina :
MALE
Laboratory's Code Worker's Code Gender
Nama Makmal QUANTUM DIAGNOSTICS SDN BHD Nama Klinik KLINIK AL-RAUDHAH (X-RAY)
& Alamat : 352, JALAN S2 B9 UPTOWN & Alamat : NO. 2, VILLAGE @ ENSTEK 71760
Laboratory's Name Clinic Name
& Address AVENUESEREMBAN 2 70300 & Address BANDAR ENSTEK NEGERI
SEREMBAN NEGERI SEMBILAN SEMBILAN

No. Telefon : 066017679 Sah Sehingga : 10/03/2020 No. Telefon Majikan :*

Telephone No. Valid Until Employer Contact No.
Tarikh Pemeriksaan : Tandatangan Doktor : Cop Klinik :
Examination Date Doctor's Signature Clinic's Stamp

Nama Pekerja : GOHAR AYUB KHAN

Worker's Name :GOHAR AYUB KHAN
Worker's Code : W6EG049081
Trans ID : 20200210966024

Worker's Name
Kod X-Ray: X26K000001 Kod Pekerja : W6EG049081 Jantina: MALE
X-Ray's Code Worker's Code Gender
No. Pasport: BZ4108973
Passport No.
Nama Fasiliti KLINIK & SURGERI TEMPLER Nama Klinik KLINIK AL-RAUDHAH (X-RAY)
X-Ray & Alamat :NO 186 JALAN BESAR 71800 NILAI & Alamat : NO. 2, VILLAGE @ ENSTEK 71760
X-Ray's Facility NEGERI SEMBILAN Clinic Name BANDAR ENSTEK NEGERI
Name & Address & Address
SEMBILAN

No. Telefon : 06-7991558 Sah Sehingga : 10/03/2020 No. Telefon Majikan :*

Telephone No. Valid Until Employer Contact No.
Tarikh Pemeriksaan : Tandatangan Doktor : Cop Klinik :
Examination Date Doctor's Signature Clinic's Stamp
 Page: 2/2

PENTING/IMPORTANT
 Tempoh sah laku Borang Pemeriksaan Perubatan ini adalah 30 hari dari tarikh pendaftaran.
The validity of the Medical Examination Form is 30 days from the date of registration.
 Berkuatkuasa pada 01 Januari 2020, sebarang permohonan untuk pembatalan dan tuntutan bayaran balik pendaftaran pekerja
asing hanya dibenarkan dalam tempoh sah laku Borang Pemeriksaan Perubatan.
Effective on 01st January 2020, any request for cancellation and refund for foreign worker's registration only will be entertained
within validity period of the Medical Examination Form.
 Sila pastikan semua maklumat di atas adalah tepat.
Please ensure that all information stated above is correct.
 Sila pastikan Borang Pemeriksaan Perubatan ini dibawa bersama passport asal untuk pemeriksaan perubatan.
Please bring along this Medical Examination Form together with the original passport for medical examination.
 FOMEMA tidak bertanggungjawab ke atas pembayaran sekiranya pemeriksaan perubatan dijalankan oleh klinik selain daripada
yang tersebut di atas.
FOMEMA will not responsible for any payment if the medical examination is carried out by medical facilities other than named above.

Prosedur Pemeriksaan Perubatan

(Untuk Perhatian Majikan)
1. Pekerja asing hanya dibenarkan membuat pemeriksaan perubatan dan X-Ray di Klinik/Pusat X-Ray seperti yang tercatat
dalam borang ini dalam masa 30 hari dari tarikh pendaftaran pekerja asing di FOMEMA.
2. Panel doktor dan pusat X-Ray FOMEMA TIDAK DIBENARKAN untuk menjalankan sebarang pemeriksaan perubatan
sekiranya pengesahan identiti dengan passport asal tidak dapat dilakukan.
3. Pekerja asing dikehendaki menjalani pemeriksaan fizikal oleh doktor terlebih dahulu sebelum menjalankan pemeriksaan
X-Ray.
4. Sila pastikan tarikh pemeriksaan doktor telah diisi oleh doktor di dalam borang ini selepas pemeriksaan fizikal dijalankan.
Majikan juga perlu menyimpan 'Salinan Majjikan' borang ini sebagai rujukan.
5. Status keputusan pemeriksaan perubatan pekerja boleh disemak dalam masa 10 hari bekerja dari tarikh pemeriksaan
perubatan dijalankan oleh doktor melalui:

 Laman Web : www.fomema.com.my

 Menghubungi Pusat Perkhidmatan Pelanggan FOMEMA di talian 03-27828777
6. FOMEMA akan menghantar rekod keputusan pemeriksaan perubatan pekerja asing ke Ibu Pejabat Jabatan Imigresen, sehari
selepas mendapat pengesahan status perubatan pekerja asing daripada doktor yang memeriksa (kecuali kes-kes yang
memerlukan siasatan lanjut).

7. Status keputusan pemeriksaan perubatan pekerja asing dari FOMEMA hanya akan berada di Jabatan Imigresen selama 180
hari dari tarikh pemeriksaan perubatan dijalankan.

Medical Examination Procedure

(For Employer's Attention)
1. The foreign worker shall only be allowed to undertake the medical and X-Ray examination at the Clinic /X-Ray Facility printed
in this form within 30 days from the date of registration of foreign worker at FOMEMA.
2. FOMEMA's panel doctors and X-Ray Facilities is NOT ALLOWED to carry out any medical examination if the identity of the
foreign worker cannot be verified against the original passport.
3. The foreign worker must undergo the physical examination by the doctor before undergoing the X-Ray examination.
4. Please ensure that the date of the medical examination is duly filled by the doctor in this form after the physical examination.
The employer should retain the 'Employer's Copy' of this form as reference.
5. The status of medical examination result can be obtained within 10 working days from the date of the medical examination by
the doctor through:

 Website : www.fomema.com.my
 Contact FOMEMA's Customer Service Department : 03-27828777
6. FOMEMA only transmits the result of the foreign worker's medical examination to the Immigration Department of Malaysia on
the following day after the foreign worker has been certified by the doctor (except for the cases that require further
investigation).

7. The status of foreign worker's medical examination result from FOMEMA will only be available at the Immigration Department
of Malaysia for 180 days from the date the medical examination was carried out.