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Cboss Sukar Submission PDF
Cboss Sukar Submission PDF
HOME ADDRESS : RUMAH RAMBA, SUNAGI LIAM, BAKONG, 98050, BARAM SARAWAK.
NATIONALITY: MALAYSIAN
HOME TEL. : -
RELIGION : CHRISTIAN
RACE : IBAN
EXPERIENCES :
Cert No:07950077
A: Personnel Data
18 Dec 1968
Full Name: SUKAR ANAK BUNDAN DOB:
ID No: 681218135677 Tel No: Occu CAMPBOSS
C: of Evaluation
" G General Work (Other than specific job)
, S1 Catering Crew
52 Confined Space Worker
53 Crane Operators
54 Electrical Worker
55 Ernergency ResPonse Team (ERT)
SO Respirator Protective Equipment User
57 Working at Height
V.1 Visitor
Operate motor vehicles or heavy machinery Pull push carry we ght over .. KG
Address: Lot 512, Ground Floor, Pelita Commercial Centre, l\,{iri, Sarawak l\4iri, Sarawak Sarawak
Tel: 085438068 Date: 9 MaY 2019 8 59:8
NOTE: MpM does not recognize this physical form as reference of medical fitness status for OSP card issuance.
Revision 4.0
Name
Vt ttco, ht B,r,rrAorn NRIC /Passporl b +l( - \e, "q L
Age
B. Type of examination
E lnitial/Renewal as
tl Return to work
C. Type of Evaluation for Offshore & Remote Onshore (As per Employer Letter/lnstruction)
tl G General work (Other than Job Specific)
This eonsent Form is introduced for the purpose of eompliance with the Personal Data Proteetion Act 2010.
: understand that:
1) Klinik Dr Cheu SB processes personal data of individuals for, amongst olhers:
(a) clinical evaluations for medical surveillanee and fltness to work assessments; and
(b) vaccinations
2) The personal data processed includes.
(a) my basic personnel data (e.g. name, date o{ birth, gender, addressl;
iUi mbOical surveillance and fitness 1o work nominatio-ns related toof my work, schedules. assessment outcomes (fiVunfii/other and
restrictions) and status, not the results. received/ not-received my laboratory test results; and
(c) specific medical data resulting-offrom my examinations, questionnaires, other visits and tests.
3) The piocessing of medical Oata inOividuals is performed by Klinik Dr Cheu SB staff. Klinik Dr Cheu SB uses my personal
information tor the following purposes:
(a) to assess my fitness to work;
(b) to recommend work restrictions and job accommodations, \
(c) for assessment and treatment purposes;
Ministry
iO) for compliance with occupational health and safety laws. includrng the requirements of MPM and its PACs or Malaysian
of Health ("MOH"); and / or lnsurance Companies
(e) on an anonymous.basis for statistics, health and safety programme improvements. scientific studies and research.
4) Only on a need to know basis, Klinik Dr Cheu SB shares my personal data, with:
(a) other health professionals for assessment and treatment purposes; and/or
in) Occupailonai heatth and safety authorities such as DOSH or MOH, as required by iaw and lnsurance companies.
5) bnty on a need to know basis, Klinik Dr Cheu SB may share my personal data with empioyer representatives, as necessary. to
inform them of Ktinik Dr Cheu SB's assessment of my medical fitness to work, which may include any work restrictions due to my
health condition. The need to know the inrormation is established through a responsibility to assist management in assignment in
work duties.
6) I acknowledge that my specific medical data under item 2(c) above rvill be stored in Klinik Dr Cheu SB Health record
system
7) This consent it valid unless il is revoked in writing
8) By signing I confirm that I have read the intbrmation in the attachment and give my consent to Klinik Dr Cheu SB to collect,
process, use, and store my personal data as described above.
Signature:
(rc* nr 4\4 Fund c^rr Date. +/oc)v
Nrte: lr.4PM AME shall enter the FTW Status into Ii/PM E-Reporting System (tvlySDS) and retained a record for future reference.
Revision 4.0
Deseription Description N
Deseription Y N N
4,Any ear discharge 25.Abnormal headbeat 45.Treated for problem of mental condilion
5,Bronchial Asthma / Bronchits 26.Hicrh blood pressure 46,Treated for problem of alcohol or drug ---1
7,Any skin trouble 28.Serious chest pain WOMAN ONLY, Have you ever had:"
9 Coughed / Vomited blood 30.Painful passage of urine 49.Any gynecological condition / treatrnent
1 l.Stomach Ulcer 32.Diabetes Will you be doing any of these specific activities;
20.Vancose Vetns
41. Fear of being enclosed li yes, amount per week? OC(
in a small space
42. Are you currently taking 59. Have you been medical disembarked from offshore
2'1.Lump in breast / arm pit Any medication? within the past 2 years? lf yes, please specify:
i tereby celify that the above information is couect to the best of my knowledge. I undersland that voluntary non-disclosure of any infornation required above is
a breach of PETRONAS ftness to work requtements and may rcsult in disciptinary action against ne, I fulher agree lo give consent lo the examining medical
proiessionals to dlsc/ose lhe resu/ts of this nedical questionnaire and associaterl nedical examination details to PETR)NAS, Petroleun Arrangement Contractor
(PAC) and my allmafters related to my Fitness to Wo* Offshore andlor Remote On.shore Worksile.
a.lr"
Signature:
"le
Note: MP[/ AME shali enter the FTW Status into lr4PM E-Reporting System (MySDS) and retained a record for future reference.
Revision 4.0
,
(l'4nt1 ([ilogram) (Kg/m,) PRESSURE Coffrcled iwtt) WIY VISION GROUP
twv w >a 1o [* uncorrected
W12[+V0A N' F{} rru tbrvp,
N A DESCRIPTION tu'IEDICAL EXAMINATI0N - Detail of findinos
1 Eyes & Pupils
2. Ear/Nose/Throat
4. Mouth
5 Respiratory
6. CardiovascularSystem
7. Abdomen
B, Hernial Orifices
L Extremities
1 0. i\4usculo-skeletal
?'ru 1l?,
1 1. Skin & Varicose Veins
12. Neurological
'13 Breasts
2. BUSE (?
3 Serum Creatinine O- V"'
4. Fasting Serum Lipid
6 Urinalysis
a. Amphetamine
b. Benzodiazepines
c.
d,
Cannabis
N4DMA tv-vh\rve
e. Opiates
f. Cocaine
8. Audiometry
9 Chest X+ay
N=Normal A=Abnormal
f] uNFtr be.ause of
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Signed:
nr. S MX (MMC a.0!1) @
hru 5.a tha (566.33-D) #sotrss
Commcrclel Ccntrc,
tiiri, lartral, h{rlrYrlr. -^Pt1t-rE
Irr: lr 5..lalCl, Cra.fltt0aS
trlore: l,rPtrt A[4E shltke...r rhc radetlt0dlfiU t{/?#Ap6fi[8 System (MySDS) anc a