HSE- Coronavirus Revision Date Published:

Number
Disease (COVID-19) #: 0
Coronavirus Disease 2019 (COVID-19) Date Revised:
Title
Emergency Management Plan

Ma‘aden Corporate – Page 1 of 3

This is a Health, Safety and Environment Mandated Standard/Procedure – Ma‘aden Controlled Entities. Before using this DISCIPLINE(S) HSE
document, check the Ma‘aden HSE Standards Web site to ensure that it is the most current version.

Screening Questionnaire for Coronavirus Disease

‫استبيان الفحص الخاص بمرض فايروس كورونا‬
Please fill the form completely and the company physician will check it upon consultation.
.‫يرجى ملء النموذج بالكامل وسوف يقوم طبيب عيادة الشركة بمراجعته أثناء اﻻستشارة الطبية الخاصة بك‬
Personal Data: :‫البيانات الشخصية‬
Full Name ‫اﻻسم بالكامل‬ Badge No. ‫الرقم الوظيفي‬ Date of Birth ‫تاريخ الميﻼد‬ Gender ‫النوع‬ Department ‫القسم‬
Mohd Adnan Jamshed Ali 21/02/1994 Male Female
‫☒ذكر‬ ‫☐أنثى‬
ID/Iqama ‫اﻹقامة‬/‫رقم الهوية‬ Nationality ‫الجنسية‬ Company ‫الشركة‬ Current living ‫السكن الحالي‬ Mobile ‫الجوال‬
2478067222 Indian Pilog Saudi Al Jubail 0532403477
International Co.
Symptoms: :‫اﻷعراض‬
Fever ‫حرارة‬ Cough ‫كحة‬ Shortness of breath ‫ضيق في التنفس‬
Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
Sore throat ‫احتقان بالحلق‬ Runny nose ‫ رشح من‬/ ‫سيﻼن‬ Nausea/vomiting ‫قيء‬/‫غثيان‬ Diarrhea ‫إسهال‬
‫اﻷنف‬
Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
Travel history: :‫تاريخ السفر‬
Have you traveled to or from outside Kingdom of Saudi Arabia within the last 14 days? Yes ‫☐ نعم‬ No ‫ﻻ‬
‫ يوما الماضية؟‬14‫هل سافرت إلى أو من خارج المملكة العربية خﻼل فترة الـ‬ Arrival date ‫تاريخ العودة‬ ☒
…………………...
Have you visited any of the following cities in KSA during the ‫ يوما‬14‫هل قمت بزيارة إحدى المدن التالية داخل المملكة خﻼل فترة الـ‬
previous 14 days? ‫الماضية؟‬
Riyadh ‫الرياض‬ Makkah ‫مكة‬ Madinah ‫المدينة‬ Al Hofuf ‫الهفوف‬ Jeddah ‫جدة‬ Al Qatif ‫القطيف‬

Yes ‫نعم‬ No ‫ﻻ‬ Yes ‫نعم‬ No ‫ﻻ‬ Yes ‫نعم‬ No ‫ﻻ‬ Yes ‫نعم‬ No ‫ﻻ‬ Yes ‫نعم‬ No ‫ﻻ‬ Yes ‫نعم‬ No ‫ﻻ‬
☐ ☒ ☐ ☒ ☐ ☒ ☐ ☒ ☐ ☒ ☐ ☒
Arrival date ‫تاريخ العودة‬ Arrival date ‫تاريخ العودة‬ Arrival date ‫تاريخ العودة‬ Arrival date ‫تاريخ العودة‬ Arrival date ‫تاريخ العودة‬ Arrival date ‫تاريخ العودة‬
…………………... …………………... …………………... …………………... …………………... …………………...
Epidemiological exposure: :‫التعرض الوبائي‬
1- Have you been in close distance less than one meter without facemask with confirmed COVID-19 case? Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
2- Have you been in close area with confirmed COVID-19 case for more than 15 min?
3- Have you got direct contact, touch with confirmed COVID-19 case, or touch something he have touched it? Date of last contact
‫ مؤكدة؟‬2019 ‫هل كنت على مسافة قريبة أقل من متر واحد بدون قناع للوجه مع حالة كورونا‬ -1 :‫تاريخ آخر مخالطة‬
‫ دقيقة؟‬15 ‫ مؤكدة ﻷكثر من‬2019 ‫هل كنت في منطقة مغلقة مع حالة كورونا‬ -2
‫ أو تلمس شيئا ً لمسه؟‬، ‫ مؤكدة‬2019 ‫هل لديك اتصال مباشر بحالة كورونا‬ -3 ………………………
1- Have you been in close distance less than one meter without facemask with confirmed MERS case? Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
2- Have you been in close area with confirmed MERS case for more than 15 min?
3- Have you got direct contact, touch with confirmed MERS case, or touch something he have touched it? Date of last contact
‫هل كنت على مسافة قريبة أقل من متر واحد بدون قناع للوجه مع حالة مؤكدة لمتﻼزمة الشرق اﻷوسط التنفسية؟‬ -1 :‫تاريخ آخر مخالطة‬
………………………
‫ دقيقة؟‬15 ‫هل كنت في منطقة مغلقة مع حالة مؤكدة لمتﻼزمة الشرق اﻷوسط التنفسية ﻷكثر من‬ -2
‫ أو تلمس شيئا ً لمسه؟‬، ‫هل لديك اتصال مباشر بحالة مؤكدة لمتﻼزمة الشرق اﻷوسط التنفسية‬ -3
Working in or attended a healthcare facility where patients with confirmed COVID-19 were admitted during Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
the last 14 days Date of last attendance
‫ يو ًما الماضية‬14‫ خﻼل الـ‬2019 ‫زيارة أو العمل في مرفق رعاية صحية أو الحضور إليه حيث تم تنويم مرضى مصابين بمرض كورونا‬ :‫تاريخ آخر حضور‬
………………………
Working in or attended a healthcare facility that had MERS case in the last two weeks Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
‫زيارة أو العمل في مرفق صحي تم فيه تنويم مريض مصاب بمتﻼزمة الشرق اﻷوسط التنفسية خﻼل اﻷسبوعين الماضيين‬ Date of last attendance
:‫تاريخ آخر حضور‬
………………………
Exposure to camel or products (directly or indirectly) in the last two weeks Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
‫التعرض لﻺبل أو منتجاتها )بصورة مباشرة أو غير مباشرة( في اﻷسبوعين اﻷخيرين‬ Date of last exposure
:‫تاريخ آخر تعرض‬
………………………

“This document is the property of Saudi Arabian Mining Company (Ma’aden), and all rights are reserved by Ma’aden. It shall not
be reproduced, transferred, modified or copied, in whole or in part, or used by or on behalf of any person or entity other than
Ma’aden or its affiliates, without Ma’aden’s express prior written permission, and must be returned on request. It is provided solely
for the purpose of disclosing Ma’aden approach and is not intended to be a recommendation for any recipient other than Ma’aden.
No warranties, guarantees or representations, express or implied are made as to the utility or effectiveness of the methods,
processes, products or procedures described or recommended herein.”
 HSE- Coronavirus Revision Date Published:
Number
Disease (COVID-19) #: 0
Coronavirus Disease 2019 (COVID-19) Date Revised:
Title
Emergency Management Plan

Ma‘aden Corporate – Page 2 of 3

This is a Health, Safety and Environment Mandated Standard/Procedure – Ma‘aden Controlled Entities. Before using this DISCIPLINE(S) HSE
document, check the Ma‘aden HSE Standards Web site to ensure that it is the most current version.

COVID 19 Vaccination: :‫لقاح كوفيد‬

First Dose ‫الجرعة اﻷولى من التطعيم‬ Yes ‫☒ نعم‬ No ‫☐ ﻻ‬ If Yes Date : ……17-05-2021……………………………

Second Dose ‫الجرعة الثانية من التطعيم‬ Yes ‫☒ نعم‬ No ‫☐ ﻻ‬ If Yes Date : ………28-06-2021…………………………

Medical conditions: :‫الحاﻻت الطبية‬

Chronic lung disease or severe Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Were you admitted in the hospital at Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
asthma least once during last 6 months
‫أمراض الرئة المزمنة أو الربو الشديد‬ ‫هل تم تنويمك في المستشفى على اﻷقل مرة واحدة‬
‫خﻼل الستة أشهر الماضية؟‬
Chronic heart diseases Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Do you suffer heart failure? Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
‫أمراض القلب المزمنة‬ ‫هل لديك قصور في عضلة القلب؟‬
Do you suffer coronary artery disease? Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
‫هل تعاني من مرض الشرايين التاجية؟‬
Did you experience heart attack at Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
least once in the last year?
‫هل توجد لديك نوبة قلبية واحدة على اﻷقل خﻼل‬
‫السنة الماضية؟‬
Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Were you admitted in the hospital at Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
Diabetes Mellitus
least once during last 6 months
‫داء السكر‬ ‫هل تم تنويمك في المستشفى على اﻷقل مرة واحدة‬
‫خﻼل الستة أشهر الماضية؟‬
Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Were you admitted in the hospital at least Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
Hypertension once during last 6 months
‫ارتفاع ضغط الدم‬ ‫هل تم تنويمك في المستشفى على اﻷقل مرة واحدة‬
‫خﻼل الستة أشهر الماضية؟‬
Kidney Failure Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Liver cirrhosis/fibrosis Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
‫الفشل الكلوي‬ ‫ تليف الكبد‬/ ‫تشمﻊ‬
Morbid Obesity (BMI >40) Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Hereditary Immunodeficiency Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
(40 < ‫السمنة المفرطة )مؤشر الكتلة‬ ‫نقص المناعة الوراثي‬
Acquired Immunodeficiency AIDS Immunosuppressive Cancer Treatment
‫اﻹيدز‬ Medications Medications
‫أدوية مثبطات المناعة‬ ‫عقارات عﻼج السرطان‬
‫نقص المناعة المكتسب‬ Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Yes ‫☐ نعم‬ No ‫☒ ﻻ‬
Other diseases ‫أمراض أخرى‬ Yes ‫☐ نعم‬ No ‫☒ ﻻ‬ Mention ‫ اذكرها‬: …………………………………………
…………………………………………
………………………………………......
.

Declaration ‫تعهد‬
I declare that the above information is correct to the best of my knowledge.
‫أتعهد بأن المعلومات أعﻼه صحيحة وأنا بكامل قواي العقلية‬
7/10/2021
Signature ‫التوقيع‬ Date ‫التاريخ‬

“This document is the property of Saudi Arabian Mining Company (Ma’aden), and all rights are reserved by Ma’aden. It shall not
be reproduced, transferred, modified or copied, in whole or in part, or used by or on behalf of any person or entity other than
Ma’aden or its affiliates, without Ma’aden’s express prior written permission, and must be returned on request. It is provided solely
for the purpose of disclosing Ma’aden approach and is not intended to be a recommendation for any recipient other than Ma’aden.
No warranties, guarantees or representations, express or implied are made as to the utility or effectiveness of the methods,
processes, products or procedures described or recommended herein.”
 HSE- Coronavirus Revision Date Published:
Number
Disease (COVID-19) #: 0
Coronavirus Disease 2019 (COVID-19) Date Revised:
Title
Emergency Management Plan

Ma‘aden Corporate – Page 3 of 3

This is a Health, Safety and Environment Mandated Standard/Procedure – Ma‘aden Controlled Entities. Before using this DISCIPLINE(S) HSE
document, check the Ma‘aden HSE Standards Web site to ensure that it is the most current version.

Only for the assessment of the attending physician ‫خاص فقط بتقييم طبيب الشركة‬

Close contact ☐ Suspected ☐ Confirmed ☐ Not a case ☐ Remarks:

COVID-19 ______________________

Close contact ☐ Suspected ☐ Confirmed ☐ Not a case ☐ Remarks:

______________________
MERS

Yes ☐ No ☐ Duration: Place:

Eligible for home
isolation Need for PCR:

No No
Eligible for referral to Yes ☐ Ambulance used: Yes ☐ Remarks:
☐ ☐
hospital for screening

Yes ☐ No ☐ Duration: Starting at: Ending at:

Eligible for suspension of
attendance to workplace Reason/remarks:

FIT UNFIT
Doctor’s Name Doctor’s Signature Clinic Stamp

Doctor on Duty

“This document is the property of Saudi Arabian Mining Company (Ma’aden), and all rights are reserved by Ma’aden. It shall not
be reproduced, transferred, modified or copied, in whole or in part, or used by or on behalf of any person or entity other than
Ma’aden or its affiliates, without Ma’aden’s express prior written permission, and must be returned on request. It is provided solely
for the purpose of disclosing Ma’aden approach and is not intended to be a recommendation for any recipient other than Ma’aden.
No warranties, guarantees or representations, express or implied are made as to the utility or effectiveness of the methods,
processes, products or procedures described or recommended herein.”