PERSONAL HEALTH DECLARATION FORM

Request Date

Name M/F*

Date of Birth Age

Company

Role

Destination ☐Jakarta Head Office ☐BSI ☐BTR-BKP ☐MTI Morowali ☐SCM Konawe ☐PGP Pani
Please answer the questions below by put √ in the appropriate answer box

No Questions Answer
1 Do you feel not fit or have an illness at this moment? ☐Yes ☐No
2 Did you experience a heart attack (cardiac attack) within 6 (six) ☐Yes ☐No
months?
3 Do you have any diabetic Mellitus with insulin injection ☐Yes ☐No
therapy?
4 Did you experience epilepsy or its reoccurrence within the last 1 ☐Yes ☐No
(one) year?
5 Did you experience dizziness (vertigo) with vomit within the last ☐Yes ☐No
1 (one) year?
6 When did you conduct the last medical check-up?
(Please provide the MCU document to doctors for review)
dd/mm/yy
7 Have you done the COVID-19 Vaccination? ☐1st ☐2nd
(Please provide vaccine certificates/recommendation letters from
☐3rd
Internal Medicine if you haven't vaccinated/completed)
8 Site entry purpose ☐Audit
☐Please state here if you choose other ☐Management visit
☐Other

9 Site visit duration ☐Less than 5 (five) days

☐More than 5 (five) days

☐I declare that the above medical statement is accurate to the best of my knowledge.
☐Therefore, I understand that Merdeka Copper Gold is only responsible for providing first aid and transportation to
Medivac up to the appointed referral hospital in case of emergency.
☐I with this release Merdeka Copper Gold from any liability concerning my medical statement as above
☐I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health condition.

Applicant Acknowledge by

Name
Title MCG Company Doctor Head of Department Site General Manager

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