1olr-Nasir Tappa (MDCL) - Compressed

OILIA MEDICAL CENTRE
CLINIC & MEDICAL CHECK-UP
MEDICAL EXAMINATION
DATE OF EXAMINATION ; April 25, 2024
COMPANY : pt.KSM INDONESIA

NAME OF THE APPLICANT ; Mr. NASIR M 0 F Q
PLACE / DATE OF BIRTH : TEMBOE, July 28“' 1975 NATIONALITY : INDONESIA
EXAMINATION FOR DUTY AS A : NO 1 OILER VESSEL NAME : SM LINE
MAILING ADDRESS OF APPLICANT : DSN TEMBOE RT/RW.O01/001 KEL. PASSPORT NO.

TEMBOE KEC. LAROMPONG
SELATAN KAB. LUWU PROV.
PHONE No.: 081355505517 SULAWESI SELATAN
MEDICAL HISTORY (Check if any medical conditions

YES NO YES NO YES NO i Yes/mo
1. MEASLES 9. SHORTNESS OF BREATH 17. PEPTIC ULCER 25. SURGICAL HISTORY □ 0
2. DIPTHERIA 10.SMALL POX 18. CHEST PAIN 26. NARCOTIC HISTORY Q 0
3. TYPHOID FEVER 11. EAR DISTURBANCES 19. SEIZURES □ 27. ALCOHOL HISTORY |~| E7I
4. LIVER DISEASE 12. NERVE DISTURBANCES 20. KIDNEY DIASEASE Q 28. SMOKING HABIT
5. ASHMA 13. THYROID DISTURBANCES 21. VENERAL DISEASE Q 29. HYPERTENSION
0g
6. BRONCHITIS 14. FREQUENT HEADACHES 30. LOSS OF VISION
22. DIABETIC
7. TUBERCULOSIS 15. HEART DIFFICULTIES 31. LOSS OF MEMORY
23. RHEUMATISM
8. MALARIA 16 FRACTURE/DISLOCATIONS Q 32. HERNIA
24. TUMOR
33. Have you ever been hospitalized ?

34. Have you ever been declared unfit for sea duties ?
35. Do You feel healthy and fit to perform the duties of your designated ?
36. Are you on medication ?
37. Are you allergic to any specific food, drugs, or other conditions such as weather ? (If yes give detail)
38. Do you free from any medical condition likely to be aggravated by service at sea or to render the seafarers unfit for such service or to
endanger the health the of other person board ?
I here by permit Shipping Company/Agency/Manning Agency and the undersigned physician to finish such information the company may need
pertainingto my tatus I here by permit by Shipping Company/Agency/Manning Agency and the undersigned physician to finish such
inf need pertaining to my health status false statement will disqualify me from employment benefits and claims.
Signature of Examinee
PHISICAL EXAMINATION
HEIGHT WEIGHT IBLOOD PRESSEURE PULSE RESPIRATORY BODY BUILT :
RATE
165 cm 60 kg Reguler Poorly Developed Fairly Developed
84 18
140/90 Well Developed Overweight
x/menit Yes No x/menit Obese
BMI: 22,04 mmHg
VISION COLOR PERCEPTION (ISHIHARA*S METHOD) HEARING NOTES/COMMENTS

VISION Without Glasses With Glasses Normal RIWAYAT HEPATITIS B
TAHUN 2023
Colorblindness |~~|yes 0no YES NO
RIGHT EYE 20/25 Right Ear
LEFT EYE 20/25 (If yes give detail)
Left Ear
BOTH EYE 20/25
Normal Normal Normal
YES NO YES NO YES NO
EYES 8. LUNGS 8. SKIN & NAILS
2. EARS 9. HEART 9. SPEECH
3. NOSE 10. UROGENITAL SYSTEM 10. HERNIA
0
4. MOUTH 11. UPPER EXTREMITIES 11. ABDOMEN
5. THROAT 12. LOWER EXTREMITIES 12. SCAR
6. THROID 13. BACK ABDORMALITY
7. LYMP NODE 14. CENTRAL NERVOUS SYSTEM 14. OTHER
Serving : Medical Check Up Seaman, Indonesia Labour, Laboratory, Rontgent, feCG, and Medication of Public
Head Office Klinik : j|, Enggano Raya Blok C No. 11 O Tg. Priok, Jakarta Utara 14310 Indonesia
Teip. : (62-21) 43900564, 43900761 Fax. : (62-21) 43900761 email : olmc_sb12@yahoo.co.id
Branch Office Klinik : ♦ JI. Swasembada Barat XII No. 2 E (Bakti Raya) Tg. Priok 14320, Jakarta Teip. : (62-21) 260 6464 8
♦ JI. Rorotan IV No. 46 A Cilincing, Jakarta Utara14140 - Indonesia Teip. : (62-21) 22 44 8 111
♦ JI. Perak Timur NO. 40 Surabaya Teip.: (62-31) 9909 2847 email: oiliasurabaya@gmail.com
Website : www.oiliamedicalcentre-olmc.com
COMPANY : PT.KSM INDONESIA
NAME OF THE APPLICANT : Mr. NASIR_____________________________ AGE : 48 Years Old
LABORATORY FINDINGS
BLOOD TgST URINE ANALYSIS
HEMATOLOGY, BLOOD CHEMISTRY, SEROLOGY / IMMUNOLOGY
SPECIFIC GRAVITY: 1.020
HEMATOLOGY PROTEIN : Negative
Hb 14.3 gr/dl GLUCOSE : Negative
WBC 8700 /uL
UROBILINOGEN : Negative
TROMBOSIT 216000 /uL
BILIRUBIN : Negative
DIFF COUNT 1/0/1/58/38/2 %
MICROSCOPIC :WBC :1 /hpt
ESR 6 mm/jam
RBC :1 /hpt
PCV 43 %
RBC 4.3 juta/uL CAST : Negative
MCV 84 fl CRYSTALS: Negative
MCH 27 pg BACTERIA : Negative
MCHC 32 g/dl COLOUR : Yellow
BLOOD CHEMISTRY
SGOT 46 U/L
SGPT 45 U/L URINE TESTING FOR ALCOHOL & DRUGS OF ABUSE
GAMMA GT (GPT) N/A ALKOHOL Negative
GLUCOSE (fasting) 108
AMPHETAMIN Negative
(2 hours after meal) 130
OPIAT/MORPHIN : Negative
(ad random)) -
TOTAL CHOLESTEROL 169 mg/dL
HDL CHOLESTEROL 45 mg/dL
LDL CHOLESTEROL 101 mg/dL
TRIGLYCERIDES 143
UREUM 29 mg/dL
CREATININE 0.9 mg/dL
URIC ACID 5.1 mg/dL
PROTEIN TOTAL N/A
BILIRUBIN TOTAL N/A
OTHER DIAGNOSTIC TEST
ALKALI PHOSPHATES N/A
Chest X - RAY Report: Normal
SEROLOGY/IMMUNOLOGY
VDRL (RPR) N/A

TPHA N/A ECG : Normal
HIV Non Reactive
HAV : N/A
: Reactive AUDIOMETRI :N/A
HBsAg
HCV : N/A
HBeAg : Non Reactive
SPIROMETRI :N/A
Anti HBsAg : N/A
STOOL ANALYSIS
TREADMILL TEST :N/A
WBC : N/A
RBC : N/A
PARASITE EGG : N/A USG ABDOMEN : Normal
AMOEBA : N/A
FAT : N/A
BLOOD : N/A
FIBER : N/A
AMYLUM : N/A
COMMENT ON MEDICAL HISTORY AND CLINICAL EVALUTION :
Theabd'venamed person
| ,Hafe mayor physical defect, fit with restriction for

dr Sarif Hidajat MS.MKes.SpCk
^elected assiggnment
■ 1 Unfit ‘ Seafarer. Physician
For'dirtidS'dri board ship KP 50172/e/DdPL/2d21
Doctors Advice : CURCUMA 3x1, CONTROL INTERNIST NAME & SIGNATURE OF
THE EXAMINING PHYSICIAN
Early detection Is Important For You To Get Healthy Life
SEAFARER MEDICAL FITNESS CERTIFICATE

No. E-240425-000714 / PG / PT.KSM INDONESIA IOLMC IIV / 24
DETAILS OF SEAFARER
Full Name Mr. NASIR

W «•<.
Place & date of birth TEMBOE, July 28* 1975
Nationality INDONESIA
Ipj *
Shipping Co./Manning Agency PT.KSM INDONESIA
Job Position / Rank NO 1 OILER
Vessel Name SM LINE
BASIS
The medical examination which cover Medical fitness, Visual system and Auditory system has been
performed and it was found that the result complies with the Medical standar of
0 State Flag of LIBERIA

□ Current ILO
□ Principal
CONCLUSION
On the basis of the above examinee's personal declaration, medical examination and diagnostic test
result recorder in the attachment; I, hereby certify thatthaatoye examinee is>medjca|lly^ a cm
.......................................... ho 1 oilert-..... ro-gE-yyH-'WSwfty^nii
DOCTOR INDICATION & SPECIAL ATTENTION ON AT WORK
CURCUMA 3x1, CONTROL INTERNIST
VALIDITY
Valid From : April 25, 2024
Valid Until : April 24, 2025
Area of validity : 0 No Restrictions
2] Restricted due to.
Note: This certificate does not cover diseases that would require special procedures and examination for their detection
Such as, Bronchiectasis, wich need bronchography; Pectic ulcer/gall bladder diseases which need cholecystograhy,
Endoscopy,etc, kidney problems which need IVP and also those which are asymptomatic at the time of examination
including psychological test and other which not cover by the above mentioned standard.
Head Office Klinik : J|. Enggano Raya Blok C No. 11 0 Tg. Priok, Jakarta Utara 14310 Indonesia
4- JI. Rorotan IV No. 46ACilincing, Jakarta Utara14140 - Indonesia Teip. : (62-21) 22 44 8 111
> JI. Perak Timur NO. 40 Surabaya Teip.: (62-31) 9909 2847 email: oiliasurabaya@gmail.com
PHYSICAL EXAMINATION REPORT/CERTIFICATE ANNEX 2
DEPUTY COMMISSIONER OF MARITIME AFFAIRS CERTIFICATE CODE :
THE REPUBLIC OF LIBERIA

LAST NAME OF APPLICANT FIRST NAME
NASIR INITIAL
DATE OF BIRTH PLACE OF BIRTH SEX
MONTH 07 DAY 28 YEAR 1975
TEMBOE INDONESIA
MALE Sf FEMALE □
CITY COUNTRY
EXAMINATON FOR DUTY' AS: MAILING ADDRESS OF APPLICANT:
MASTER EZ3 RATING CT
DSN TEMBOE RT/RW.01/01
MATE I......... J MOU DECK CZI KEL. TEMBOE KEC. LAROMPONG SEKATAN
ENGINEER I I MOU ENGINE I I KAB. LUWU
RADIO OFF I I SUPERNUMERARY I I
MEDICAL EXAMINATION (SEE PAGE 2) STATE DETAILS ON PAGE 2

HEIGHT WEIGHT BLOOD PRESSURE PITS! RESPIRATION GENERAI APPEARANCE
165 60 140/90 84 18 LOOKING HEALTY
VISION: RIGID LYE LEFT EYE
WITHOUT GLASSES ___ 20/25... . / „20/25
WITH GLASSES /
DATEOFLASTCOLORVlSIONTEST(MunthDav/Year) 04/25/2024 TestmgRequireJ every 6 years
COLORVISIONMEETSSTANDARDSINSTCW'CODI:.TABLEA-I/9'? EZ) YES CSS NO
COIDR TEST TYPE: B<KJKy<IANTERN CHECK IF COLOR TESTIS NORMALYELLOW Ef RED Sf GREEN ST BLUE 5?
ui i au NORMAL NORMAL
K t (.AK * LEEi EAR
HEAD AND NECK HEART (CARDKIVASCULAR)
NORMAL NORMAL
LUNGS SPEECH (DECKNAVIGATONAI. OFFICER AND RADIO OFFICER)
LS SPEECH UNIMPAIRED FOR NORMAL VOICE COMMUNICATION?
NORMAL NORMAL
EXTREMITIES:
UPPER normal LOWER FORMAL
IS APPLICANT SUFFERING FROM ANY DISEASE LIKELY TO BE AGGRAVATED BY, OR TO RENDER HIM UNFIT FOR SERVICE AT SEA OR LIKELY
TO ENDANGER THE HEALTH OF OTHER PERSONS ON BOARD? IF YES, EXPI AIN IN DETAILS OF MEDICAL EXAMINATION ON PAGE 2.
25/04/2024 24/04/2025
APPLICANT DATE OF EXAM EXPIRY DATE
THIS SIGNA TURE SHOULD BE AFFIXED IN THE PRESENCF OF THE EXAMINING PHYSICIAN.
THIS IS TO CERTIFY THAT A PHYSICAL EXAMINATION WAS GIVEN TO NASIR

"(NAME OF APPLICANT)
(HE) (SHE) IS FOUND TO BE (FTI) ###### FOR DUTY AS A: (.##########. ########1^1####### RATING,
IF EMPLOYED AS A WATCHSTANDER (HE) (Oft IS FOUND TO BE (ITT) (#ftft#ft#FOR LOOKOl^lffiljgff_____________
NAME AND DEGREE OF PHYSICIAN dr- SARIF HIDAJAT Ms.Mkes.SpOk pr-g
ADDRESS JL ENGGANO RAYA BLOK C NO 11 o JAKARTA - INDONESIA

------------------------------------- -------------------------------------------------------------- ------£-i---------S=4---------------------
NAME OF PHYSICIAN’S CERTIFICATING AUTHORITY 0ILIA MEDICAL CENTRE„ I—J _______
DATE OF ISSUE OF PHYSIClA^fsfoRTinCATD BS-SEPTEMBER 2021________________________ Q

\<| . r "'JI' VX ■
•________
SIGNATURE OF PHYSICIAN DATE OF EXAMINATION 25/04/2024

This certificate is issued by authority of the Deputy Conwm"iini^r of Maritime Affairs, R.L. and in compliance with the
requirements of the Maritime Labour Convention, 2006 for the Medical Examination of Seafarers.
The Medical Certificate shall be valid for no more than two (2) years from the date of the Examination for those over 18
years of age and for no more than one (1) year for those under 18 years of age.
RLM-105M (REV. 12/17) 1
MEDICAL REQUIREMENT
All applicants for an officer certificate. Seafarer's Identification and Record Book or certification of special
qualifications shall be required to have a physical examination reported on this Medical Form completed by a
certificated physician. The completed medical form must accompany foe application for officer certificate, application
for seafarer's identity document, or application for certification of special qualifications. This physical examination
must be carried out not more than 12 months prior to the date of making application for tin officer certificate,
certification of special qualifications or a seafarer's book. Such proof of examination must establish that the applicant
is in satisfactory physical condition for the specific duly assignment undertaken and is generally in possession of
all body faculties necessary in fulfilling the requirements of the seafaring profession. In addition, the following
minimum requirements shall apply:
(a) Ail applicants must have hearing unimpaired for normal sounds and be capable of hearing a whispered
voice in the better ear at 15 feet and in foe poorer ear at 5 feet.
(b) Deck officer applicants must have (either with or without glasses) at least 20/20 vision in one eye and al
least 20/40 in tlte other. If the applicant wears glasses, he must have vision without glasses of at least
20/160 in both eyes. Deck officer applicants must also have normal color perception and be capable of
distinguishing the colors red. green, blue and yellow.
(c) Engineer and radio officer applicants must have (cither with or without glasses) at least 20/30 vision in one
eye and at least 20/50 in the other. If the applicant wears glasses, he must have vision without glasses of at
least 20/200 in both eyes. Engineer and radio officer applicants must also be able to perceive the colors red,
yellow and green.
(d) An applicant's blood pressure must fall within an average range, taking age into consideration.
(c) Applicants afflicted with any of the following diseases or conditions shall be disqualified, epilepsy,
insanity, senility, alcoholism, tuberculosis, acute venereal disease or neurosyphilis. AIDS and/or the use of
narcotics.
(f) Deck/Navigational officer applicants and Radio officer applicants must have speech which is unimpaired
for normal voice communication.
(g) Applicants for able seafarer deck, bosun. GP-1. ordinary seaman and junior ordinary seaman must meet
the physical requirements fora deck/navigational officer's certificate.
(h) Applicants for fireman/watertender, oiler/motorman, able seafarer engine pumpman, electrician, wiper,
tankerman and survival craft/rescue boat crewman must meet the physical requirements for an engineer
officer’s certificate.
DETAILS OF MEDICAL EXAMINATION

(To be completed by examining physician)
RLM-105M (REV. 12/17) 2

HASIL PEMERIKSAAN LABORATORIUM

REPORT LABORATORY RESULT
Nama Pasien NASIR Nama Perusahaan PT.KSM INDONESIA

Patien Name Company Name
Umur 48 Tahun Tanggal Pemeriksaan April 25, 2024
Age 48 Years Old Examination Date
Jenis Kelamin Laki - Laki No Lab E-240425-000714
Sex Male Lab Number
NIK / Passport Dokter Pemeriksa dr. Arbi Kardiyanto
ID. Number / Passport Examiner Doctor
dr. Freddy Ciptono, Sp.PK
PEMERIKSAAN HASIL NILAI RUJUKAN SATUAN KETERANGAN

LABORATORY TEST RESULT REFERENCES RANGE SET OF REMARK
BLOOD CHEMISTRY
Glucose Fasting 108 70-110 mg/dl
Glucose Post Prandial 130 < 140 mg/dl
ALT 45 0-41 U/L
AST 46 0-37 U/L
Cholesterol 169 <200 mg/dL
HDL 45 30-65 mg/dL
LDL 101 < 130 mg/dL
Trygliserid 143 <200 mg/dL
Uric Acid 5.1 3.4-7.0 mg/dL
Creatinine 0.9 0.7-1.4 mg/dL
Urea N 29 15-42 mg/dL
Hematology
ESR 6 < 10 mm/jam
Haemoglobin 14.3 13.0-18.0 gr/dl
White Blood Cell Count 8700 4300-10000 /uL
Hematocrit / PCV 43 39-54 %
Red Blood Cell Count 4.3 4.3-5.8 juta/uL
MCV 84 80-93 fl
MCH 27 26-31 pg
MCHC 32 32-36 g/dl
Trombosit 216000 150000 - 450000 /uL
DIFF COUNT
Eosinofil 1 <3 %
Basofil 0 <1 %
N. Batang 1 1-3 %
N. Segmen 58 20-70 %
Limfosit 38 20-50 %
Monosit 2 0-8 %
IMMUNOLOGY
HBsAg Reactive Non Reactive
HBeAg Non Reactive Non Reactive
Anti HIV Non Reactive Non Reactive
Head Office Klinik : J|. Enggano Raya Blok C No. 11 O Tg. Priok, Jakarta Utara 14310 Indonesia
Teip. : (62-21)43900564, 43900761 Fax. : (62-21)43900761 email: olmc_sb12@yahoo.co.id
♦ JI. Rorotan IV No. 46ACilincing, Jakarta Utara14140 - Indonesia Teip. : (62-21) 22 44 8 111

Nama Pasien NASIR Nama Perusahaan PT.KSM INDONESIA

Umur 48 Tahun Tanggal Pemeriksaan: April 25, 2024
Jenis Kelamin Laki - Laki No Lab : E-240425-000714
Sex Male Lab Number
NIK / Passport Dokter Pemeriksa : dr. Arbi Kardiyanto
PEMERIKSAAN HASIL NILAI RUJUKAN

LABORATORY TEST RESULT REFERENCES RANGE
Preparat
Preparat BTA
BTAI Negative Negative
Head Office Klinik : J|. Enggano Raya Blok C No. 110 Tg. Priok, Jakarta Utara 14310 Indonesia
Teip. : (62-21)43900564, 43900761 Fax. : (62-21)43900761 email : olmc_sb12@yahoo.co.id
Branch Office Klinik : 4- JI. Swasembada Barat XII No. 2 E (Bakti Raya) Tg. Priok 14320, Jakarta Teip. : (62-21) 260 6464 8
4- JI. Rorotan IV No. 46 A Cilincing, Jakarta Utara14140 - Indonesia Teip. : (62-21) 22 44 8 111
4. JI. Perak Timur NO. 40 Surabaya Teip.: (62-31) 9909 2847 email: oiliasurabaya@gmail.com

Nama Pasien : NASIR Nama Perusahaan : PT.KSM INDONESIA

Umur : 48 Tahun Tanggal Pemeriksaan : April 25, 2024
Jenis Kelamin : Laki - Laki No Lab : E-240425-000714
Sex Male Lab Number
PEMERIKSAAN HASIL NILAI RUJUKAN

LABORATORY TEST RESULT REFERENCES RANGE
Drug Test
Amphetamin Negative Negative
Opiat/Morphin Negative Negative
Alkohol
Alkohol Negative Negative
Urinalysis
Chemical Analysis
pH 6.0 5.0 - 8.5
Protein Negative Negative
Glucosa Negative Negative
Urobilinogen Negative Negative
Bilirubin Negative Negative
Keton Negative Negative
Microscope Analysis
Erythrocytes 1 <2
Leukocyte 1 <3
Cylid Negative Negative
Epith Cells Positive Positive
Bacteria Negative Negative
Crystal Negative Negative >
Specific Gravity 1.020 1.000- 1.030'
Colour Yellow Yellow /
Didtorisasi oleh,
Qualtxyelidator
Head Office Klinik : J| Enggano Raya Blok C No. 11 O Tg. Priok, Jakarta Utara 14310 Indonesia
HASIL PEMERIKSAAN GIGI

DENTAL CHECKUP REPORT
Nama Pasien NASIR Nama Perusahaan ; PT.KSM INDONESIA

Umur 48 Tahun Tanggal Pemeriksaan : April 25, 2024
Jenis Kelamin Laki - Laki No Pasien Gigi : E-240425-000714
Sex Male Dental Patient Number
NIK / Passport Dokter Pemeriksa : drg. Indriyani Komalasari
CHIEF COMPLAINT
FINDING :
1. TEETH MISSING
8,7,6 6
£
2. CARIES TEETH
4
3. PERIODONTALLY INVOLVED TEETH
4. OTHER : 28,34 GR, CALCULUS+++
ADVICE : PRO SCALLING, 28,34 PRO EXO
Head Office Klinik : J| Enggano Raya Blok C No. 11 0 Tg. Priok, Jakarta Utara 14310 Indonesia
PERNYATAAN HASIL TEST NARKOBA DAN ALKOHOL

DECLARATION OF DRUG AND ALCOHOL RESULT
No. E-240425-000714 / PT.KSM INDONESIA / OLMC / IV/24
Dengan ini, soya menyatakan bahwa, hasil tes narkoba dan alkohol atas nama:
I Declare that drug and alcohol test Result From:
Nama Mr. NASIR

Name
Perusahaan PT.KSM INDONESIA

Company
Jabatan NO 1 OILER
Rank
Jenis Kelamin Male

Sex
Umur 48 Years Old

Age
Alamat DSN TEMBOE RT/RW.001/001 KEL. TEMBOE KEC. LAR0MP0N6

Address SELATAN KAB. LUWU PROV. SULAWESI SELATAN
Diperiksa untuk keberadaan obat-obatan berikut dan alkohol dalam urin menggunakan metode
penyerap immonoassay/chomatographic competitive dan ditemukan:
Was examed for the presence of the following drugs and alcohol in the urine using the Competitive
Immonoassay/Chomatographic Absorbent Method and was found:
Significant Alcohol Level in Blood was : Negative

Amphetamin : Negative
Opiat/Morphin : Negative
Jakarta, April 25, 2024

Yang Membuat Pernyataan
This ^geWratign Sign By’
dr. SKes.SpOk
'O. Seafarefr Physician
KP §01/2/e/DJPL/2021
*- L IN' '
Medical Review Officer
PERNYATAAN HASIL TEST ANTI HIV

DECLARATION OF ANTI HIV TEST RESULT
No. E-240425-000714 / PT.KSM INDONESIA / OLMC / IV/24
Dengan ini, saya menyatakan bahwa, basil tes anti HIV atas nama:
I Declare that anti HIV test Result From:
Nama : Mr. NASIR

Name
Perusahaan : PT.KSM INDONESIA
Company
Jabatan : NO 1 OILER
Rank
Jenis Kelamin : Male
Sex
Umur : 48 Years Old
Age
Alamat : DSN TEMBOE RT/RW.001/001 KEL. TEMBOE KEC. LAROMPONG

Address SELATAN KAB. LUWU PROV. SULAWESI SELATAN
Is : NON REACTIVE
Demikian pernyataan ini dibuat dengan hasil yang sebenar-benarnya.

This is to certify that the test is correct and true.
Jakarta, April 25, 2024

Yang Membuat Pernyataan
This ttO'n Sign By
Jai^MSnMKes SpOk
er Flfysician
Teip. : (62-21) 43900564, 43900761 Fax. : (62-21) 43900761 email: olmc_sb12@yahoo.co.id
4- JI. Rorotan IV No. 46 ACilincing, Jakarta Utara14140 - Indonesia Teip. : (62-21) 22 44 8 111
HASIL PEMERIKSAAN ECG

REPORT ECG RESULT
Nama Pasien NASIR Nama Perusahaan : PT.KSM INDONESIA

Jenis Kelamin Laki - Laki No. ECG : E-240425-000714
Sex Male ECG Number
ID. Number/Passport Examiner Doctor
Irama : Sinus Rhythm

QRS Rate : 88x/minute
PR Interval : Normal
QRS Duration : Normal
ST-T Changes : Negative
Arrhytmia : Negative
RVH/LVH : No
Conclusion : Normal
dr. Pandu NurcahydMLirti Sp.JP, FIHA
01 LI A MEDICAL CENTRE
HASIL PEMERIKSAAN USG Upper & Lower Abdomen

REPORT USG Upper & Lower Abdomen RESULT

Age 48 Year Old Examination Date
Jenis Kelamin Laki - Laki No. USG Upper & : E-240425-000714
Sex Male Lower Abdomen
Liver : Large and normal shape regular edges and tapered liver tip
omogeneous structure of the normo-echoic parencyma no solid
or focal lesions were seen cystic the intrahepatic biller and
vascular structures are not dilated. There were no ascites or
pleural
Gall Bladder : Big and normal shape, Regular thin walls no rocks and
intraluminal sludge
Pancreas : Large and normal in shape, no focal and absent lesions were
seen pancreatic duct dilation
Lien : Large and normal shape, homogeneous parencymal structure

invisible focal lesion and no splenic vein dilatation
Right Kidney : Large and normal in shape, the cortex and medulla structure is
good, not visible stones or focal lessions. There is no sign of
system obstruction pelviocalises and right ureter
Left Kidney : Large and normal in shape, the cortex and medulla structure is
good, not visible stones or focal lessions. There is no sign of
system obstruction pelviocalises and left ureter
Buli - Buli : Large and normal shape, regular thin walls no visible focal
lesions and there are no intralumen stones.
Prostat Gland : Large and normal shape Homogeneous parenchyma structure

There were no focal or calcified lesions.
Other : -
Conclution : Abdominal Organs And Pelvic Organs Within Nof0atl_imits.
dr. Tengkd barmy Yanti, Sp.Rad
Head Office Klinik : JI. Enggano Raya Blok C No. 11 O Tg. Priok, Jakarta Utara 14310 Indonesia
HASIL PEMERIKSAAN Thorax PA

REPORT Thorax PA RESULT

Age 48 Year Old Examination Date
Jenis Kelamin Laki - Laki No. Thorax PA : E-240425-000714
Sex Male Thorax PA Number
ID. Number/ Passport Examiner Doctor
The Lung field : no infiltrates in both field of the lung The hilar is normal
Brochovascular marking is normal
The Heart & Aorta Normal
Costophrenic sinuses and Normal

diaphragms
Other abnormality : NIL
Conclusion HEART AND LUNG NORMAL
Review by,
Head Office Klinik : j|. Enggano Raya Blok C No. 11 O Tg. Priok, Jakarta Utara 14310 Indonesia
Branch Office Klinik : -4 JI. Swasembada Barat XII No. 2 E (Bakti Raya) Tg. Priok 14320, Jakarta Teip. : (62-21) 260 6464 8
PERSETUJUAN PEMERIKSAAN HIV ANTI BODY

CONSENT FOR HIV ANTIBODY TEST
Examinee Name
Company/Agency
Psni fn do n
Gender (V) Age lyg Years old
Exam Date
'2£7'2X/ -O'j - 2A~
Crew Id
7 5/7/0 2.7 077 Wool
1. KEGUNAAN
PURPOSE
Tes ini menentukan apakah anda terinfeksi oleh Human Immunodeficiency Virus (HIV). Tes ini bukan merupakan tes untuk Acquired
Immunodeficiency Syndrome (AIDS) yang mana memerlukan evaluasi medis secara lengkap.
This test determines whether your may have been infected with the Human Immunodeficiency Virus (HIV). This test is not a test for
Acquired Immunodeficiency Syndrome (AIDS) which can only be diagnosed by an extensive medical evaluation.
2. HASILTES POSITIF
POSITIVE TES RESULT
Jika ternyata hasil tes anda menunjukkan hasil positif kemungkinan anda telah terinfeksi oleh Human Immunodeficiency Virus (HIV). Anda
memerlukan pemeriksaan lebih lanjut bicarakan dengan dokter anda.
If you test positive, you may infected with HIV. You should seek medical follow up with your doctor.
3. KEAKURATAN
ACCURACY
Hasil tes ini dapat dipastikan 100% akurat. Kemungkinan dapat terjadi hal-hal sebagai berikut:
a. Positif Palsu
Hasil tes menunjukkan positif meskipun anda tidak terinfeksi Human Immunodeficiency Virus (HIV). Hal ini jarang terjadi. Tes
ulang perlu dilakukan untuk memastikan hasilnya apakah benar-benar positif atau tidak.
b. Negatif Palsu
Hasil tes menunjukkan negative meskipun anda telah terinfeksi Human Immunodeficiency Virus (HIV). Hal ini sangat mungkin
terjadi pada seseorang yang sedang terinfeksi virus HIV dini: untuk menjadi positif diperlukan waktu sekurang-kurangnya 4-12
minggu.
The test result is not 100% accurate. Possible errors include:
a. False Positive
The test gives a positive result, even though you are not infected This happens only rarely. Re testing should be done to help
confirm the validity of positive test.
b. False Negative 0
The test gives a negative result, even though you are infected with HIV. This most likely to happen in recently infected person: it
takes at least 4 to 12 weeks fir a positive test result to develop after a person is infected.
PERNYATAAN PERSETUJUAN
Saya menyatakan bersedia untuk menjalankan pemeriksaan antibodi HIV setelah hal-hal tersebut dibawah ini saya pahami.
Saya telah membaca maksud dan tujuan pemeriksaan antibodi HIV ini.
Saya telah diberikan kesempatan untuk bertanya tentang informasi lebih lanjut tentang pemeriksaan tersebut dan saya telah pendapatkan
jawabannya secara memuaskan.
Dengan ini saya memberikan persetujuan untuk dilakukan pemeriksaan HIV terhadap diri saya atas permintaan perusahaan/agen jasa
tenaga kerja yang akan mempekerjakan saya I secara pribadi*
Saya menyatakan memberikan kuasa dan ijin kepada dokter pemeriksa / Medical Review Officer untuk memberitahukan hasil
pemeriksaan antibodi HIV yang telah saya lakukan kepada perusahaan / agen jasa tenaga kerja / fleet medical department.
/ have read the above information and understand the purpose of this tets.
I have been given the opportunity to ask the question and obtain further information and all of my question have been answered to my
satisfaction.
I give permission and authorize the examinee physician/medical review officer to inform the result of myVHVantibody test to the company
/manning agecy /fleet medical department.
Tanggal / Date
dr. Arbi Kardiyanto

W WfflaW Blok C No. 11 0 Tg. Priok, Jakarta Utara 14310 lnMWean ?ng Meminta Persetuiuan
Head Office
S'9nOtureWW^43900564. 43900761 Fax. : (62-21)43900761 email
♦ JI. Perak Timur NO. 40 Surabaya Teip. : (62-31) 9909 2847 email: oiliasurabaya@gmail.com

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OILIA MEDICAL CENTRE

CLINIC & MEDICAL CHECK-UP

COMPANY : pt.KSM INDONESIA

PLACE / DATE OF BIRTH : TEMBOE, July 28“' 1975 NATIONALITY : INDONESIA

EXAMINATION FOR DUTY AS A : NO 1 OILER VESSEL NAME : SM LINE

MAILING ADDRESS OF APPLICANT : DSN TEMBOE RT/RW.O01/001 KEL. PASSPORT NO.

MEDICAL HISTORY (Check if any medical conditions

33. Have you ever been hospitalized ?

VISION COLOR PERCEPTION (ISHIHARA*S METHOD) HEARING NOTES/COMMENTS

VDRL (RPR) N/A

| ,Hafe mayor physical defect, fit with restriction for

SEAFARER MEDICAL FITNESS CERTIFICATE

Full Name Mr. NASIR

0 State Flag of LIBERIA

2] Restricted due to.

THE REPUBLIC OF LIBERIA

MEDICAL EXAMINATION (SEE PAGE 2) STATE DETAILS ON PAGE 2

COLORVISIONMEETSSTANDARDSINSTCW'CODI:.TABLEA-I/9'? EZ) YES CSS NO

THIS IS TO CERTIFY THAT A PHYSICAL EXAMINATION WAS GIVEN TO NASIR

NAME AND DEGREE OF PHYSICIAN dr- SARIF HIDAJAT Ms.Mkes.SpOk pr-g

ADDRESS JL ENGGANO RAYA BLOK C NO 11 o JAKARTA - INDONESIA

DATE OF ISSUE OF PHYSIClA^fsfoRTinCATD BS-SEPTEMBER 2021________________________ Q

SIGNATURE OF PHYSICIAN DATE OF EXAMINATION 25/04/2024

DETAILS OF MEDICAL EXAMINATION

RLM-105M (REV. 12/17) 2

HASIL PEMERIKSAAN LABORATORIUM

Nama Pasien NASIR Nama Perusahaan PT.KSM INDONESIA

dr. Freddy Ciptono, Sp.PK

PEMERIKSAAN HASIL NILAI RUJUKAN SATUAN KETERANGAN

HASIL PEMERIKSAAN LABORATORIUM

Nama Pasien NASIR Nama Perusahaan PT.KSM INDONESIA

dr. Freddy Ciptono, Sp.PK

PEMERIKSAAN HASIL NILAI RUJUKAN

HASIL PEMERIKSAAN LABORATORIUM

Nama Pasien : NASIR Nama Perusahaan : PT.KSM INDONESIA

dr. Freddy Ciptono, Sp.PK

PEMERIKSAAN HASIL NILAI RUJUKAN

HASIL PEMERIKSAAN GIGI

Nama Pasien NASIR Nama Perusahaan ; PT.KSM INDONESIA

3. PERIODONTALLY INVOLVED TEETH

4. OTHER : 28,34 GR, CALCULUS+++

ADVICE : PRO SCALLING, 28,34 PRO EXO

PERNYATAAN HASIL TEST NARKOBA DAN ALKOHOL

Nama Mr. NASIR

Perusahaan PT.KSM INDONESIA

Jenis Kelamin Male

Umur 48 Years Old

Alamat DSN TEMBOE RT/RW.001/001 KEL. TEMBOE KEC. LAR0MP0N6

Significant Alcohol Level in Blood was : Negative

Jakarta, April 25, 2024

PERNYATAAN HASIL TEST ANTI HIV

Nama : Mr. NASIR

Alamat : DSN TEMBOE RT/RW.001/001 KEL. TEMBOE KEC. LAROMPONG

Demikian pernyataan ini dibuat dengan hasil yang sebenar-benarnya.

Jakarta, April 25, 2024

HASIL PEMERIKSAAN ECG

Nama Pasien NASIR Nama Perusahaan : PT.KSM INDONESIA

Irama : Sinus Rhythm

dr. Pandu NurcahydMLirti Sp.JP, FIHA

HASIL PEMERIKSAAN USG Upper & Lower Abdomen

Nama Pasien NASIR Nama Perusahaan : PT.KSM INDONESIA

Lien : Large and normal shape, homogeneous parencymal structure

Prostat Gland : Large and normal shape Homogeneous parenchyma structure