A sister Concern of Thermax Group

Garments Division
Korardi, Shibpur, Narsingdi-1600, Bangladesh

DRUG SCREENING FORM

PARTICULAR

1. Name
2. Father’s Name 3. Mothers’ Name
4. Spouse’s Name
5. Present Address :
6. Age: 7. Height 8. Weight

CONSENT OF FACTORY WORKER

I solemnly declare that all the information mentioned on this page are true and correct to the best of my
knowledge any information found untrue then my authority could take legal action against me. ( Avwg
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Signature (¯^vÿi ) or Thumb-impression ( wUcmwn)

Date :

MEDICAL EXAMINATION (Done under good daylight and Privacy)

If any body is addicted to drug or alcohol then the following symptoms are shown.

1. Sleep disturbance: Yes No

2. Abnormal sensitivity to noise: Yes No
3. Nervous Physical activity, like scratching : Yes No
4. Irritability, dizziness or confusion: Yes No
5. Extreme anorexia: Yes No
6. Tremors or even convulsions: Yes No
7. Tachycardia: Yes No
8. Bradycardia: Yes No
9. Hypertension: Yes No
10. Presence of inhaling paraphernalia, razor blades, mirrors, and straws. Yes No
11. Physical effects, such as liver, kidney and lung damage/problem: Yes No

DOCTOR’S COMMENTS
Based on above findings this person is free from drug abuse: a) She/he is fit for work
b) She/he is not fit for work

Doctor’s Name & Sign with Seal