Uncontrolled when printed

ASSURE HSSEQ
Contractor Health Questionnaire Form

This health questionnaire will be held confidentially in the Methanex Medical Centre and will be used in the event of an emergency.

Company you work for:

First Name: Surname:

Date of Birth: Home Phone Number: Mobile Number:

Your Address:

Your Emergency Contact Name: Their relationship to you: Their Contact Number:

Your Company Supervisors Name: Your company phone number:

Do you have a medical history or condition that may affect your health and safety or that of others on the plant
site? (e.g. dizziness or blackouts etc.)
□ No □ Yes (please explain what it is)

Are you presently taking any prescription or non-prescription medications?

□ No □ Yes (name what you are taking)

Are you aware of any health reasons that would prevent you from working in certain work environments or that
the Methanex Medical team should be aware of?
e.g. claustrophobia, epilepsy, asthma, heart disease, diabetes, allergies)
□ No □ Yes (please explain)

Other: (e.g. Contact lenses worn, work restrictions etc.)

□ No □ Yes (please explain)

I have answered these questions honestly and to the best of my knowledge.

Signature: Date:

Please email a scanned copy to: NZHealth@methanex.com PRIOR to arriving at site

Code: HS4NZZZ1013 Issue date: 05-Nov-2020 Page 1 of 1
Approved: Manager - Responsible Care Revision No. 10