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 18/03/2020
Kod Perkerja: W54N081022
Worker's Code
Name Pekerja : NURLIANA SIREGAR No. Pasport : AU242757
Worker's Name Passport No.
Jantina : FEMALE Negara Asal : INDONESIA
Gender Country of Origin
Tarikh Lahir : 12-11-1976 Tarikh Pendaftaran : 18-02-2020
Date of Birth Date of Registration
Telefon Majikan : 019-3121999 Majikan : AISHARINI BINTI ZULKIFLI
Employer Contact No. Employer
No. Telefon Doktor : 03-41497945 No. Telefon X-Ray : 03-41497945
Doctor Telephone No. X-Ray Telephone No.
Sah Sehingga : 18/03/2020 Kod Majikan : E84A018722
Valid Until Employer's Code :

Tarikh Pemeriksaan :
Examination Date
Kod Doctor : D74S000020 Kod Pekerja : W54N081022 Jantina : FEMALE
Doctor's Code Worker's Code Gender
Nama Doktor : SELLAMAH A/P SELLAPPAN No. Pasport : AU242757
Doctor's Name Passport No.
Nama Klinik KLINIK SETAPAK DAN SURGERI Nama Pekerja : NURLIANA SIREGAR
& Alamat : NO 39 1/27 TMN DESA SETAPAK Worker's Name
Clinic's Name WANGSA MAJU 53300 SETAPAK KUALA LUMPUR Sah Sehingga : 18/03/2020
& Address Valid Until

No. Telefon : 03-41497945 No. Telefon Majikan :019-3121999 Tandatangan Doktor : Cop Klinik :
Telephone No. Employer Contact No. Doctor's Signature Clinic's Stamp

Nama Pekerja : NURLIANA SIREGAR

Worker's Name :NURLIANA SIREGAR

Worker's Code : W54N081022
Trans ID : 20200218509357
Worker's Name
Kod Doctor : D74S000020 No. Pasport : AU242757
Doctor's Code Passport No.
Kod Makmal : L1EP000001 Kod Pekerja : W54N081022 Jantina :
FEMALE
Laboratory's Code Worker's Code Gender
Nama Makmal PATHLAB HEALTH SERVICES SDN Nama Klinik KLINIK SETAPAK DAN SURGERI
& Alamat : BHD & Alamat : NO 39 1/27 TMN DESA SETAPAK
Laboratory's Name Clinic Name
& Address WISMA KAM 87-91 JALAN SS 25/2 & Address WANGSA MAJU 53300
TAMAN BUKIT EMAS 47301 SETAPAK KUALA LUMPUR
PETALING JAYA SELANGOR

No. Telefon : 0378098188 Sah Sehingga : 18/03/2020 No. Telefon Majikan :019-3121999
Telephone No. Valid Until Employer Contact No.
Tarikh Pemeriksaan : Tandatangan Doktor : Cop Klinik :
Examination Date Doctor's Signature Clinic's Stamp

Nama Pekerja : NURLIANA SIREGAR

Worker's Name :NURLIANA SIREGAR
Worker's Code : W54N081022
Trans ID : 20200218509357

Worker's Name
Kod X-Ray: X34K000085 Kod Pekerja : W54N081022 Jantina: FEMALE
X-Ray's Code Worker's Code Gender
No. Pasport: AU242757
Passport No.
Nama Fasiliti KLINIK SETAPAK DAN SURGERI Nama Klinik KLINIK SETAPAK DAN SURGERI
X-Ray & Alamat :NO. 39, JALAN 1/27B TAMAN DESA & Alamat : NO 39 1/27 TMN DESA SETAPAK
X-Ray's Facility SETAPAK 53300 SETAPAK KUALA Clinic Name WANGSA MAJU 53300
Name & Address & Address
LUMPUR SETAPAK KUALA LUMPUR

No. Telefon : 03-41497945 Sah Sehingga : 18/03/2020 No. Telefon Majikan :019-3121999
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.