STATEMENT OF GOOD HEALTH

I, (name of CiC) , certify that I am in good health and fit to work full
time. I also confirm that I have been informed and acquainted myself of the inoculations required for the
country or countries to which travel may be authorized as stated in my contract with the Independent
Investigative Mechanism for Myanmar (IIMM).

I also confirm that I shall assume all costs that may occur in relation to this Statement of Good Health,
and that I take full responsibility for the accuracy of this statement.

Furthermore, should I be required to travel, I also certify that my Medical or Health Insurance covers
medical evacuations and treatment.

I will submit proof of my travel insurance covering medical evacuations and treatment for the period of
my travel under the IIMM contract prior to initiation of the travel request by IIMM.

I will not undertake any official travel for IIMM without submission of the travel insurance.

Sign in (place and date)

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Signature