PTs 18.13.01 December 2017 Page 68 of 73 APPENDIX 3: MEDEX FORMS Remark: The most up to date MEDEX Forms and formatted for clinic use are available at the GHSSE website. Those without access to the website, to contact Occupational Health GHSSE. 6 ‘MEDEX 001, HEALTH DECLARATION AND CONSENT FORM sats To8e commrED By CANDIDATE /BHMOYEE rane TATE Tra Tanne tenn veecrgrt Taner [Ronn he eros wore aie cr | owe tense 0 TOUNAYE OR MAVEYOU HAD: RO) 7 [reap 3 ene er a IRE SR Tae 2] wearer weer a iene eT a Cr = [Grea zee 3 [ie eb tg 3 [aso arg nom SSS = [tie =| merer ve acon 7 | Ngee 7 | vr se eae a ron act ng sy boca song pte 3 [ena cance a 2 ee Sf eatneaiaa | ung oaa ap Hi facceete 1 | eee cen Se i | tortie Fee «=| Eater ne 1a [conse vont aod | oer Keer spear 37 [oem ST 3 | seco se mer [iiss 7 [woer ome 2 2 [ec 13 sete 35 [nme a raestneoe Tonwoneh onthe os 3 [re new se oo Cn ore — [Geresenstareset wane] [Bevoumie neice? reo iyeaomtpereet? Nave any of your famiy members sutered rom the folowing? [[TJossees Drewes Cosme Clowes Dlccom [scr socapreuce — Doasncenace Cees come —— Jeronenaractna FT cateey ragesaa MEDEX 001 6 Declaration & Consent Statement | the uncenignd, declare an crt thatthe daoure af the above information hasbeen made weuntatiy and that the infrmation gan above trae and complete tothe best of my browledge. | urdertane that fle deaation of ary infermation reqted above may result dcpnary acon anor eal rocedrgs being aken against me. Fer Fess To Wrkheath assesament including pre-employment, Inerby sve content othe eamining Medic Came 10 diclone the information ger ths MEDEX forms andthe resuit of my heat asesiment tothe Company Heath Advisors andor authorzed PEIRONAS Persone! for the puposes of management ofa mates related 12 PETROWAS amplyment poceset. For brevetve Mesh stassment (renin) Uncestanl that meccl dts wil be anaes ssorynauty for the purpose ‘of th PETRONAS neath an wellness program implementation. My percna identity wil rat be revealed at any som of rays nor wil tbe ued for Fitness To Werk ar empioyment processes | understand thot PETRONAS shall endesvur to implament the sppropistesecunty safeguards and administrate procecurs in acordance withthe applicable local avs and regulations to prevent unautharze or unaws processing age anc aciental loa of destruction fo earage to, ny Pascal Dat Uhre red, understood and accep the conten of thi Content Ststement gen herein and | hereby gv my consent or PETRONAS to manage my Personal atin the PETRONAS Occupetcral Heath Database Site. Ienpyet estonare rene nave seat oe (amciadea aia) pagentSE Page 70 of 73 MEDEX 002 {NX HEALTH ASSESSMENT @ PETRONAS ETT 1 (CPreempleymet| (Cee evr) Cee rercoment [Coonestc Centon (Csaccent Cs (Coes psec numoaastewn) neermtouene [ Ciebspecte Cote (Cnet cnton Comoniebspecte nates) CPt a — aHeee mer —— pees eee aaa os |[7] Fre Fighter ane emergency Dorie T] Werk requires colour Perception —(] Auxiliary potice Seo ee oe ee couser | Onmares as l aS BOUTON ] sete] ete] oe ] eee] wt] [] tere]oe 6 Hen Aes FoR TNESSTO WORK re MEDEX 002 HEALTH ASSESSMENT oS eet eer eee rertees A Lungs / chest: " ca cm “ wom Swe ce ce cm tee” che omer chee bee MIM er ex eee cet ‘seen & ainsi nigel Rear I TR TAROT TET j aor ce CA Cm 7 seumcearsies CN GA OMA 2 chetenny ceck om 2 serum pds cue om 08 cece om eC uenkentnn CH CA Oh Aumprncente CHCA souwenmesonret Cw CA Chk pte GEE GHEE Ge nats cr ck om se rtingnbodchcoe CW 22 Wine ogee CW oe eevee pon te] woe ite Auer Test 5s [HT anne eae | ae 1. 20 30 a so cry - = = os coos te ees emeres momey | as 1. 20 30 40 oo 20 rd = a = ab lh |S mE Sey Se ee ee cele along eePTS 18.13.01 6 HEALTH ASSESSMENT FORFNESSTO WORK oo Permonas Page 72.01 73 MEDEX 003 FITNESS TO WORK CERTIFICATE PETRONAS a “set cry that have amin the sbve med prion and unde Festa a en (Cecenoermen = [oom [Trmewet Dame Deswacorw Mec Adis / onsation ToEmgioyeePTS 18.13.01 © | sesurvassessneur ron ress 10 wore ican Paros Page 73 of 73 MEDEX 004 6 PETRONAS ENDORSEMENT BY HEALTH ADVISOR FINAL ENDORSEMENT RESULT employee'sname: stat le Passort No, Employee's FTW status [i Preemploynent Final Endorsed Result Fit/Fewnh Restriction /Unft Next Due: reroaie Fina Endorsed Resut: Ft /Ftwith Restriction /Unit Net Due irrepiecement Final Endorsed Result Ft /Fewith Restriction / Unf Next Ove: [I en Final Endorsed ResutcF/Ftwah Restriction /Untt Net eT [Broo spect Job-spectic Type Finl Endorsed Result Fit / Fic with Restriction / Unf ext Ove [NT Job-specie Type 2 inal Endorsed Resut Fr/Ft with Resrcton /Unft. Next Ove [cerns Final Endorsed Result: Fie / Ft with Restriction / Unfit Next Oue (Blox cause For Cause Type, Fil Enorsed Resi: r/R wen Rermcien /Unte Nex Out (NN [Bbrenmte wore etn to Work Type: Final Endorsed Resut FF wit Resin [Unt Newt Ove Tndoreement marke ee Adar Sgr ate