Fit To Work Certificate

Date of examination: 03, October 2023

Place of examination: HCB, Beira – Mozambique
Medic conducting Fit To Work assessment: yes

Patient Name: Faride Antonio M. Osmane Birth Date: 18-12-1980 Age: 43

Position: EDD K9 Handler Location of Work: Somalia Gender: M

BP: 120/80mmhg RESP: 12-20 Weight: 78 BMI: 18.5

HEALTH INFORMATION
(Patient to complete)
Have you needed to consult a health professional in the last twelve months? If Yes, give details (reason,
outcome): No

Are you currently undergoing treatment for any health problem, including dental? If Yes, give details
(problem, treatment, dosage): No

Do you have a chronic illness or affliction e.g. cardiovascular disease, diabetes, mental condition
etc? If Yes, give details (problem, treatment): No

Have you required emergency admission to hospital during the last five years? If Yes, give details (dates,
problem, outcome): No

Have you ever required specialist treatment for an illness, including for a mental health problem? If Yes,
give details (dates, problem, outcome): No

Have you had any illnesses, operations or injuries which have caused you to be off work for more than four
weeks? If Yes, give details (problem, treatment): No

Have you ever left employment for health reasons e.g. medical retirement? If Yes, give details
(when, diagnosis, treatment): No

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 Have you had any other condition requiring hospital treatment or investigation? If Yes, give details (dates,
problem, outcome): No

Have you ever suffered any medical condition which could incapacitate you at work e.g. epilepsy, severe
migraine, severe asthma, vertigo, blackouts? If Yes, give details (when, frequency, cause): No

Do you have or have ever had any health problems or disability that:

 Affects your mobility e.g. back injury / strain / pain / disc problems / sciatica?
 Restricts your ability to undertake physically demanding tasks?
 Renders you liable to injury?
 Reduces your resistance to infection?
 Impairs vision or hearing?
 Require special equipment or support to enable you to work independently?
 Do you have any other disabilities?

If Yes to any of the above, please give details below: No

Are you allergic to any medicines? If Yes, please give details (name of medicine, type of reaction): No

FIT TO WORK DECLARATION:

Following a Fit To Work health assessment, the aforementioned patient is deemed…


x Fit without restrictions
 Fit with restrictions
 Unfit
…to carry out their duties in the role of EDD Handler in Somalia.

If fit with restrictions please specify:

…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………

This Fit To Work certificate will remain valid for 12 months.

Patient signature: …………………………………

Medic signature: …………………………………

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