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Personnel information gathering form

I. Identification Please complete


1 Surname: PAINO
2 First Name: IRWANTO
3 Qatar ID or Passport number: E0744874
4 Nationality: INDONESIA
5 Blood type and Rhesus A+
6 Employer: SUBSEA 7
7 Employee number: 427620
8 Job position: WELDER
PPE ☐ I am wearing glasses
II. Personnel Category Please tick
A Offshore worker ☒
B Onshore worker, making offshore visits ☐
C Onshore worker, exposed to industrial risks ☐
D None of the above ☐
III. Documents to provide (if not already transmitted to NOC OH Nurse) Please tick
1 Fitness To Work certificate * ☒
2 * Medical FTW dossier if certificate is not issued by OGUK, ☒
NOGEPA, OLF or Danish Maritime Authority registered doctor
3 Copy of the Qatari ID or Passport with work visa ☐
4 Photo (passport size J-PEG format) ☒
5 Copy of current medical fitness offshore card (if applicable) ☒
Data per each e-mail should not exceed 18 Mb in size
The provided confidential medical data shall be administered by NOC Occupational Health personnel only

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