Version 4.

0
ll
MEDEX OO3 t il*l'.,
11i,":1i i:
FITNESS TO WORK CERTIFICATE
FETROHAS

t,mployee EGAL EDDIE Staff/NRIC/Passport No. 98113012s639

'fhis is to certify that I have examined the above named person and found his/her fitness status as follows

ASSESSMENT TYPE RESULT NEXT DUE

/ Unlit / Fit with
Fit volidity/Expiry oote
of the ossessment (dd.frn.YYYY)
h$pactoe Restriction

f Pre-employment FrI 0?.05,b76

U
f Pre-Placement

f, For-Cause

f Return to Work

Specific Type l.Confined SPace Worker Unfit

fiJob
Type 2.Breathing ApParatus User Unfit

Type 3.Working at heights Unfit

RES'I'RIC'I-ION INFO:
fl roa

f ounnlottt

f locnrtoru

Restriction End Date @dmnywy)

Remaf kS TO HR (For UnfiUFWR cases, kindly state the risk and implication if the candidate/staff is allowed to work)

ITEMPORARY UNFI f FoR ALL JoB sprsrrrc. Ftr FoR GENERAL PLANT AND FIELD woRlt.^
./l
1t e one .
I

I
il

Medical Advice / Consultation To Employee

PLEASE REDUCE WEIGHT

t_
I

orvrijJr"li"d ;;;;i;;; ;,;;;'f( I

DdtQ ua.^..wwt 03.05.2024

f.IAflIl'|ER
AME's/Medical Examiner Namc : On nltZU1 BIN JALAL
Clinic Name : KLINIK ESPLANAD SIPITANG DR FAIZI.'I BIN JALAT
DR FA]ZUL BIN JALAL ESPIAI.IIffSIPITANG
MB BCh BA0 (lreland) MMC 57351 AME'S stamp
Petronas AME (SB 008)
D0sH 0HD H0/16/D0C/00/460
l;er:erat€(l an c.rll.:rl:4 14::5: I: MR0 2021-775 PageloflreDEia)ll
Klinik Esplanad Sipitang Sdn thd (1185818'D)
^ 1:]] PETROLIN NASI'NAI BERHrc lPETR'NAS
Alt rrghts reserved. No part of Lhis.ontent may be reproduLred, sLored rn a retrieval system or tr.nsmrtled rn any form or by any means (electtonrc, me.hanrcal, phoro,:opylnq, re:ordlng or
.rhererse, wrLhout lhe permrssron of rhe ropyrrght o{ner.
 Untuk diisi oleh kontraktor
MEDEX

DEKLARASI KESIHATAN DAN BORANG PERSETUJUAN (KONTRAKTOR)

OO1
6
PETRONAS

Nama penuh:
swt {ea4e- No. rClPassport,
1(qq0)'l--5 Ol No tereron:011_ t OO q gVb
Alamat rumah/majikan: q rrp * n
l, g
&qb av1
Tempat pemeriksaan: fS pta ,t farikh lahir: ?3 0 tt
rari*n:1zl
/0
l$18
Posisi pekerjaan:

Adakah anda mempunyai atau pernah mempunyai: (tandakan ,ya,

atau ,tidak,)

Ya Tida k Ya Tida k YA Tidak

1 Resdung 23 Gatrik / ulcer Masalah mental (e.g.,
44
2 Alaha n 24 Kerap sneak perut kemurungan)
3 Masalah kulit 1C
Bengkak / penyaklt hati 45
Masalah dengan dadah /
alcohol
4 Discaj telinga 26 Penyakit hempedu
Adakah anda pernah:
5 Eengkak leher / kelenjar Naik/susut berat badan
)7 Terdedah kepada
6 Masalah dental mendadak
bahaya kesihatan
28 Masalah usus
7 Sakit kepala / Migraine 46 seperti bunyi bising,
Masalah buah pinggang debu, bahan kimia,
8 Pening/Pitam 29
/batu karane radiasi etc?
9 Angin Ahmar 1n Sakit waktu kencing Mengalami penyakit
10 Sawa n
31 Darah dalam air kencing tempat kerja seperti
Ketumbuhan payudara 47 asma, masalah kulit,
11 / 5Z Buasir/Hernia
ketia k penyakit darah, hilang
Kerap jangkitan paru- 33 Darah dalam najis pendengaran etc?
l2 Pernahkah anda
paru 34 Vena Varikos
13
mendapat keputusan
Sesak nafas Masalah sendi/ tulang
35 tidak normal untuk ujian
t4 belakans 48
Batuk / muntah darah pendengaran / ujian
15 Asma
36 Gout
D( fungsi paru-paru / X-Ray
37 Kencing Manis paru-paru?
16 Tuberkulosis
38 Barah (Cancer) Adakah anda
1.7 Sakit dada teruk 49 mempunyai penyakit
Denyutan jantung tidak 39 Pem bedaha n
la i n-la in ?
18
normal
40
Kemalangan / UNTUK PEREMPUAN SAHAJA - Adakah anda
19 Penyakit jantung Kecedera a n pernah mempunyai: -
4L Takut akan ketinggian 50 Masalah ginekologi?
20 Darah tinggi
Takut akan ruang
2t Penyakit darah 47 51 M enga ndung?
terkurung
22 Sakit perut teruk Sedang mengambil apa-
43
apa ubat?

Adakah anda merokok/vape? l@ ia.f, Adakah anda kerap mengambil alcohol? V.l@ Kalau ya, berapa kuantiti seminggu?

Adakah keluarga anda mempunyai penyakit-penyakit berikut?

Kencing manis E Angin ahmar tr

Darah tinggi tr penyakit Penyakit darah E
 MEDEX OO1

6
PETNONAS

Declaration & Consent Statement

l, the undersigned, declare and certify that the disclosure of the above information
has been made voluntarily and that the
information given above is true and complete to the best of my knowledge. I
understand that false declaration of any
information required above may result in disciplinary action and/or legal proceedings
being taken against me.

For Fitness To work health assessment including pre-employment, I

hereby give consent to the examining Medical Examiner
to disclose the information given in this MEDEX Forms and the result of my health assessment to the Company Health
Advisors and/or authorized PETRoNAS Personnel for the purposes of management of all matters related to pETRoNAS
employment processes.

For Preventive Health assessment (screening), I understand that

medical data will be analysed anonymously for the purpose
of the PETRoNAS health and wellness program implementation. My personal identity
will not be revealed at any point of
analysis nor will it be used for Fitness To work or employment processes.

lunderstand that endeavour to implement the appropriate security safeguards and administrative
PETRoNAS shall
procedures in accordance with the applicable local laws and
regulations to prevent unauthorized or unlawful processing,
usage and accidental loss or destruction of/or damage to, my personal
Data.

I have read, understood and accept the contents of this consent statement given
herein and I hereby give my consent for
PETRONAS to manage my Personal Data in the PETRONAS
Occupational Health Database System.

(Employee)

Questionnaires reviewed by:

DR FAIZUL BIN JALAL
MB BCh 8A0 (lreland) [l[,lC 57351
Petronas AME (SB 008)
DosH 0HD H0/16/D0C/00/460

,^," *th(*ry
MR0 2021.775
Klinik Esplanad Sipilang Sdn thd (118581&D)
Name: si'nature: f Date:

(AM E/Medical Examiner)

Page 2 of 2
Version 4.0

MEDEX OO2
HEALTH ASSESSMENT
PETRONAS

CIear All Fields

l-lealth Advisor Code HR Email N/A

Employee Name SIEGAL EDDIE Staff Number N/A

lC Number / KIP No. 981 130r.25639 Passport Number

ASSESSMENT TYPE

C Pre-employment f Pt-tS - Periodic (Preventive) f exit

Pre-Placement C Domestic r^ lnternational

Cause
f Post Accident C Suspicion I Prolong lllness & MBO f- Others (prease speciry in MEDEXoo3's Remark)

Return to Work f Job Specific f offshore f Remote Location

C Non Job Specific (post injury/illness) C Post MRP

Job Specific

f] offsrrore ffi Breathing Apparatus User f, food Handler D Remote Location

ffi Confined Space Worker fl Crane and/or Fork Lift Operator I nadiation Worker I Health Care Worker

[_l t,ire tighter and Emergency

I Driver I Work Requires Colour Perception I Auxiliary Police
Response Personnel

ffi Working at heights

EXAMINATION

weight(kg)ffi rreight(m)llsg*l BMr

EA ratz
l-l waist-tlipnatio
f] up(mmHe)f3;l /H purse(per.in)flo
J

Distance Vision Near Vision Color Vision

U ncorrected R 6/6 L 6/6 R L

Normal
Corrected R L R L

GenerdLed on i9.Lrl-:ara4 r4:i5: ?

:I]:: TETRO!IN NASIONAL BERHM lPETRONAS)

AII rrghts !eserved. No parL of rhrs con!ent may be reproduced, srored 1n a retrievat sysrem o! rn any form or by any means (electronrc, mechanrcal, phorocopyrng, r.:',r.rrl! :r
otherwrse) urthour the permrssion of the copyrlghr owner.
Version 4.0

MEDEX OO2
HEALTH ASSESSMENT
PETRONAS

Employee EDDIE Staff/NRIC/Passport No. 98113012s639

N = Normal, A = Abnormal, NA = Not Applicable Default all to Normal

1 Eyes 6 t't fn Crun 8 Skin ON fn (^ NA

2 Ear, Nose & Throat 6tt fn Crun 9 Varicose Veins 6 l,t fa lrun
3 Oral / Teeth 6 trt fa CNA 10 Extremities/ f r,t r*A {^ NA
Musculoskeletal
4 Lungs / chest 6ru Cn CNe (-e
11 Neurological (aN rNA
5 Cardiovascular 6N Ca c rrA
L2 Genitourinary (^N fr 6rua
5 Abdomen 6N Cr f rrrl (^N fn 6rua
13 Breast
7 Hernia Orifices 6 r't fn fua 14 Anus &Rectal f ttt Cn 6run
Examination

Assessments & Examinations Finding/Medical Remarks

CTINICAL AND TABORATORY TEST RESULTS

1 Audiometry 6ru (.n rNA 7 Serum Electrolytes 6tt r-A Cun

2- Chest X-Ray C rrt fn 6NA I Serum Lipids C r.t (6A CNA
3 ECG fN fn 6run 9 Urea & Creatinine 6 rrr fA (- NA

4 Lung tunction Test 6 t't Ca fun 10 Liver Function Test CN {iin fru
5 Full Blood Count 6tt fA frun 11 Urinalysis Otl Cn Cun
5 Fasting Blood Glucose 6ru fn Cna 12 Urine DrugTest O trt fn rNA

rot"t chot[__l.,orlr Fasting Btood ctu.or"li!-_lmmor/L Btood crplo* I str"r, t"rt[-_l pap Smearl-l ur.rnogrr*[--l
Audiometry Test Results (RIGHT ) Lelt btonk il there's no votue

Frequency Avg Avg Avg

0.5 1.0 2.0 3.0 4.0 6.0 8.0
(KHz) 0.5,L,2 0.5,1,2,3 2,3,4

dB

Audiometry Test Results llEFTl rc1t tton* i1 therc's no votue

Frequency Avg Avg Avg

0.5 1.0 2.O 3.0 4.0 6.0 8.0
(KHz) o.s,t,2 0.5,1,2,3 2,3,4

dB

Additional Tests Findings/Remarks

CLASS 2

lf yes / applicable, kindly select (X) relevant box (conrirmed diasnosis only)

f] oiabetes Meltitus fl Hypertension I lschaemic Heart Dlsease I Bronchial Asthma fi Smoking / Vaping

Prepared by : DR FAIZUL BIN JALAL

Generared on 09.01.2024 I4:2s:12 Page2of 2 MEDEI!!:

:O:: PETROLIN NASIONAL BERHrc (PETROMS)

A11 rlghts reserved. No part of lhrs conient may be leproduced, srored in a rerrieval sysrer or tlansmitted ln any form o! by any means {electronic, hechanrcal, photocopyrng, recordrng or
.therwrse) wrthout lhe permrssron of lhe copyrrght owne!.
 6 JESSELTON LAB
WE CARE FOR YOU

Patient Name
lClPassport No
SIEGAL EDDIE
981 1 301 25539
LABORATORY REPORT

Date Request 29/04/2024

D.O.B -30/11/1998 Age : 25 Doctor Dr. Faizul Bin Jalal
Sex Male ClinicA/t/ard Klinik Esplanad Sipitang
Date/Time of Collection i 29/04/2024 08:00:00 Barcode No 24002412

BIOCHEMISTRY

Result Ref. Ranges

DIABETIC SCREEN ffiE'ETOT

Fasting Blood Sugar EEfiHH 4.5 mmol/L <6.5
HbAlc ffiftmrIEH r' 6.2 % Diagnostic Value
< 5.7 Normal
5.7 - 6.2 Pre-diabetes
> 5.5 Diabetes

LIVER FUNCTION TEST [+IDSE&E

Total Protein,HtrE 89 g/L 60-82
Albumin EEE 42.9 g/L 35.0 - 50.0
Globulin fiEE * 46 20-39
s/L
AST (scor) m,=f*H+tfiEffi * 223 U/L <41
ALr (sGPr) m=i*F5EEm+€fi8ffi * 117 U/L <51
GGT F*5EI+TWW * 72 U/L <51
ALP [dEffiMEE 71 U/L 40 - 129
Total Bilirubin,B[E4I* 11 umol/L <21

RENAL FUNCTION TEST '5UAEf;ftT

Sodium tB * 133 mmol/L 135 - 145
Potassium f,il " 7.49 mmol/L 3.50 - 5.10
Badly lysed sample.

Chloride fr 95 mmol/L 9s - 110

urea E* 6.0 mmol/L 2.5 - 8.0
Creatinine flrlffimffi 67 umol/L s0 - 116
Uric Acid Em * 725.00 pmol/L 208.y)--fr.00

*r
I
DR'FAIZUL BIN JALAL
[,lB BCh BA0 (lreland) MMC 5735'l
Petronas AME (SB 008)
DosH 0HD H0116/D0C/00/460
MR0 2021.775
Klinik Erplanad Sipilang Sdn Bhd (118581&D)

Unit l-27 Level l, JQ Cenkol, Coostol Highwoy. OFF Jolon Tun Fuod Stephen, 88400 Koto Kinobolu. Tel No. : 0BB-288 989
 JESSELTON LAB
WE CARE FOR YOU
LABORATORY REPORT

Patient Name SIEGAL EDDIE

lClPassport No 981 1 301 25639 Date Request : 29/04/2024
D.O.B 30/11/1998 Age : 25 Doctor ; Dr. Faizul Bin Jalal
Sex Male Clinic/Ward : Klinik Esplanad Sipitang
i
Date/Time of Collection 29/04/2024 0g:00:00 Barcode No i 24002412
eGFR {fiH'Edrl*irEit'* 127 mL/min/1.73m^2 >50

NKF Classification of Chronic Kidney Disease

Stage Description I Cf n

1 Normal or High GFR I gO*

2 Mild decrease in GFR I OO-AS

3 Moderate decrease in GFR 30-59

4 GFR I
Severe decrease in lS-Zg
;-- KidneyFailure I .tS

Calcium tE 2.38 mmol/L 2.02 - 2.60

lnorganic Phosphate mHEiltBflIUE * 1.90 mmol/L 0.81 - 1.62

LIPID PROFILE fr]FIFEE&T

Total Cholesterol fl Eftlg$ * 7.0 mmol/L 35.2
Triglycerides =MEI;fiEE * 3.47 mmol/L <1.68
HDL Cholesterol EBEEEEEflEtrH 1.03 mmol/L > 1.03
LDL Cholesterol,fftEtrEEEEflEtrEg * 4.34 mmol/L <2.58
Chot / HDL Ratio E/r=EEflEtrEFtL{E * 6.7 mmol/L < 5.0

MB BCh BA0 (tretand) MMC

5235t
Pekonas AME (Sg 008t
DosH oHD Ho/r6/boc/ooh6o
MR0 2021.775
Klinik Esptanad Sipirang Sdn
Bhd (11858t&D)

br-r---
of5
RIQAS$
Unit l-27 Level l, JQ Centrol, Coostol Hiqhwoy, OFF Jolon Tun Fuod Stephen, 88400 Koto Kinobolu. Tel No.
: 0gg-2gg ggg ]
 JESSELTON LAB
WE CARE FOR YOU
LABORATORY REPORT

Patient Name SIEGAL EDDIE

lC/Passport No 981 1 301 2s639 Date Request -
29/04/2024
D.O.B 30/11/1998 Age : 25 Doctor Dr. Faizul Bin Jalal
Sex Male Clinic/1/tlard Klinik Esplanad Sipitang
Date/Time of Collection i 29/04/2024 08:00:00 Barcode No 24002412

HAEMATOLOGY

Ref. Ranges

FULI BLOOD COUNT fiMHflffiI

Haemaglobin fi4I* 15.7 13.0 - 18.0
9/dL
Red Blood Cells 4Trlnlg 5.2 x10^12/L 3.8 - 5.5
PCV 4rrnffiEH 0.46 L/t 0.40 - 0.54
Mcv +qmffiEfR 89 t/L 76-96
MCH +€'f'EBEM4]EE 30 p9 27 -33
MCHC +fr'JfrBqfr'IEE;fitr 34 g/dL 30-37
RDW-CV 1lfri*rr\Hffitr-cv 12.9 o/o
11.0 - 15.0
TotalWhite Cells EfuH
" 11.4 x1 0^9/L 4.0 - 11.0
Platelet Count frdrffi 393 0^ 9/L
x1 150-400
ESR ITIfNI*R[++ 15 mm/hr <22

Differential Counts EFitfi

Neutrophils E+t+$ 55 o/
/o 40-75
Lymphocytes ttEI* 34 o/
/o 20-45
Monocytes 4&I* 9 o/o
2-10
Eosinophils F"ilfqs. o/
2 /o 1-6
Basophils EIOEEftS 1
o/
/o 0-2
BLOOD FILM frHH
Peripheral Blood Film mrEE{trffiH
Hb: Normal.
RBC: Normochromic normocytic.

WBC: Morphologically normal.

Platelet Adequate.
IMP: Normal parameter for age and sex of the patient.

.,,,,,#,'l,ffi,1llifi1l;fl
,

=.....-
Unit l-27 Level l, JQ Centrol. Coostol Highwoy, OFF Jolon Tun Fuod Stephen, 88400 Koto Kinobotu. Tel No. : 0g&2g8
 JESSELTON LAB
WE CARE FOR YOU
LABORATORY REPORT

Patient Name SIEGAL EDDIE

lClPassport No 981 1 301 25639 Date Request i 29/04/2024
D.O.B 30/11/1998 Age : 25 Doctor ; Dr. Faizul Bin Jalal
Sex Male Clinic/Ward : Klinik Esplanad Sipitang
Date/Time of Collection : 29/04/2024 08:00:00 Barcode No :24002412

BLOOD GROUP fr4

ABO Group fi4 o
Rh (D) trr +

+
DR FAtrZUL BIN JALAL
MB 8Ch 8A0 (tretand) MMC 57351
Pekonas AME (SB 00E.1
00sH 0HD H0/16/0oc/00/460
MR0 2021.775
Klinik Esptanad Sipilang Sdn Bhd (118581&D)

RIQAS
ffil,CoostolHighwoy,oFFJolonTunFuodStephen,88400KotoKinobolu.TelNo.:08B-288989l
 JESSELTON LAB
WE CARE FOR YOU
LABORATORY REPORT

Patient Name SIEGAL EDDIE

!C/Passport No 981 1 301 2s639 Date Request 29/04/2024
D.O.B 30/11/1998 Age : 25 Doctor Dr. Faizul Bin Jalal
Sex Male Clinic/Ward Klinik Esplanad Sipitang
Date/Time of Collection i 29/04/2024 08:00:00 Barcode No 24002412

Ref. Ranges

URINE FEME Ei&H*flf;ftT

Urine Clarity ,|.ifl Clear
Urine Colour ffiE Amber
Urine SG RhZE. 1.020 1.000 - 1.030
Urine pH Effi[ril{E 5.0
Urine Leucocytes EEfuffi Negative Negative
Urine Blood E,Em Negative Negative
Urine Nitrite lEIHffiH Negative Negative
Urine Ketone EEE,f4\ Negative Negative
Urine Bilirubin EEEII* Negative Negative
Urine Urobilinogen EEE*IF Negative Negative
Urine Protein EEE Negative Negative
Urine Glucose Effi Negative Negative
Urine Casts EtrE Negative Negative

Microscopic EHHffi!5
Urine WBC/hpf EIEBE 0 /hpf 0-3
Urine RBC/hpf fi4.gg 0 /hpf 0-5
Urine Epithelial Cells/hpf L&:ffiffi 0 /hpf 0-10
Urine Casts EtrE Negative Negative
Urine Bacteria E<frH' Negative Negative
Urine Crystal E#,RIfr Negative Negative

PROMO1 BG

DR FAEUL BIN JAI.AL

MB 8Ch BA0 (lteland) MMC 57351
Petronas AME (SB 008)
D0sH 0HD H0116/00c/00/460
MR0 2021-775
Klinik Esplanad Sipitang Sdn Bhd (1185818'D)

This is a computer generated report. No signature is required.

Final report
Date-Reported: 3o/04/zoz4 Validated by: Ellen Hamonangan

S,,(reoon.a, ro,oo,og - --L*--*-a&

ffitrol,CoostolHighwoy,oFFJolonTunFuodStephen,884ooKotoKinobolu.TelNo.:088-2889891
Pulmonary Function Test Results

Visit date 2910412024

Patient code 981130125639 Age 25
Surname EDDIE Gender Male
Name SIEGAL Height, cm 168
Date of birth 30/11/1998 Weight, kg 101
FVt FWl FEVIo/o Ethnic aroup Oriental BMr 35.79
LL- L-- PRE +
EllT1--ffi:,@11 Smoke Smoker Pack-Year 2
Patient group

11
PR.E PRE
12

1CI 6

^5
J o
Hr
^4
.A F3
JL- l?

2
Lo
1
I PreOicteO

-4 4 5 E fTirne I
ia^i
I 10 't't 12 13 14 15

-8
Quality @ntrd Grade: D
-o 1 Acceptable trials
' '.- Predicted
-10 InErpretaUon d
2 345
Volume
NormalSpirometry
iL)

PRE Trial date 29lO412024 1O:47:1O AM

Parameters LLN Pred Be$t o/oPred Z-score PRE#1 PRE#2 PRE#3 POST o/oPred o/oCh9
FVC L 3.68 4.69 4.23* 90 -0.75 4.23 *
FEV1 L 3.17 4.01 3.59x 90 -0.82 3.s9 *
FEVI/FVC oto
70.9 82.7 84.9x 103 0.31 84.9 *
PEF Us 7.40 9.39 6.02* 54 -2.78 6.02 *
El3 Years 25 39 156 39
FEF2575 Us 3.t7 4.88 4.01 82 -0.84 4.01
FET s 5.00 5.27 88 5.27
FIVC L 3.68 4.59
FEVII/C vo 70.9 82.7
*Best values from all loops - BTPS ,..087 26 oc (78.8 oF) - Predicted ERs (Eccs)
I Knudson
Conclusion / Medical
DR FAIZUL BIN JALAL
MB BCh BA0 (keland) i,lMC 57351
Petronas AME (SB 008)
D0sH 0HD H0/16/D0C/00/460
Signature MR0 2021-775
Instrument used
KliniI Esplanad Sipitang Sdn Bhd (1185818.0)
II S/N Cl1205
Minispir
Last calibration chwk2910412024 8:38:17 AM

OR FAITULBOIJAI.AL
Inilt
Klinik Erplanrd $pthng Sdn BM (ttEit8.D)

orinted bv winspiroPRo 7.9.0 - Mod.C11 1lL ,N\ltllR

 KLINIK KESIHATAN PEKERJAAN
Graphic Audiogram Analysis
Name: SIEGAL EDDIE Audiometermodel: SM930
lD / Passport No: 98l 130125639 Calibrationdate: 09.11.2022
DOB: 30/'1111998 Operator: DYMNAH @ NORHAYATI
Dale. 0210512024 Audiogram no: 1 DOSH approvalno

5k 1k 1.5k2k 3k4k 6k8k .5k 1k 1.5k2k 3k4k 6k8k

0 Left 0 Right Baseline Test Date:2910412024
10 10
l.-;i*rri-.-
-i'i'\lt i-i -,rF 20 % Loss
2_0
F-i i lt
---Nl./" i
30 i-----i'---: -i'
I I 30 Left Right Binaural
40 r-
i ---r----!-.1 ---L-iy'--, i
i- -i-i---i-,4-- 40
50 50
60 60 5k 1k 1.5k 2k 3k 4k 6k 8k
70
Left 25 20 20 20 25 40 15 15
80 80
90 90 Right 20 20 20 20 20 20 10 10

Total Loss incured 1eft00000 000

Malaysian Standards
from first test to last test RightO 0 0 0 0 000
(a) OSH (Noise Exposure) Reg.: 201 9 Hl= Current test thresholds averaged over 0.5,1 ,2,3 k{z >= 25 dB either ear
(b) OSH (Noise Exposure) Reg. 201 9: STS = Shift from baseline thresholds averaged over 2,3,4 kHz >= 10 dB either ear
(c) O&G Fitness to work: Fail = Current test threshold averaged over 0.5,1 ,2 k1z > 35 dB in the better ear

Left ear Right ear Number of tests: 1

(a) OSH Hearing lmpairment Normal 22dB Normal 20dB

(b) Standard Threshold Shift NA STSL NA STSR
(c) O&G Fitness to work
t 21dB Pass 20dB

Not enough data to provide full assessment (needs min 2 tests)

on 4l2ul BIN JALAL

MB BChFAO (lreland) MMC 5i351
Pelronas AME (SB 008)
D0sH 0l'lD H0/16/00c1001460
MR0 2021'775
Klinik Esplanad Sipitang Sdn Bhd (1185818'D)

KLINIK KESIHATAN PEKERJAAN Page 1 Powered by Workplace Audiometrics

 APPENDIX 4
STI T RIC TESTIN
NAIVIE
AGE
:
uwl SEX xaab Q/)i feruale (
:
CON4PANY
IC/PASSPORT NO.:
SECTION
Do ttttt proceed witlt ttrtdioutetric testiug !).
if!1!ruOXl:
Do you pla.y lotrd ruusical iustrrruteuts,?
lhe worker hos cttttrlilittn.r, tltot mq) (U\.ect lhe
y,rltt (Etamltle: colrt, gltltllness,
lesl
tiniiis YES T_]
erc.1.
If YES, please detail:
PIense tick EI rvhicheyer. r.elev:tut. 10. Have you rvor.kerl irr noisy jobs iu the past.?
(obs
L Were vou expclserl to loutl ur.lise ivhere you hacl cr.-rruuuurication difticuir-v due
lo
prior t0 today's test? noise)?
YES tf l:?f
If YES
t_] delail:
pleasr.r
No Z
(l{Ii?ltON: l.l' "1,E,1., please_ rtborl rttrrl rescltedult ,, ).\:!l1.
\,t'rrr rvearius pc.r.sonal hc.aring pr.orr,cror.s
leslirtg tt'illt ort tttlt,ice to ut,oid loucl troi.te ll ltottrs. (PHP) ar rlrar rirrre (referlirrs ro O t0)?
prior to tesl.
):!: D
If \TS. type otpt-ip:
no a
I{iive 1,q11 sufl.ererl auy 111u.., that lias atfected Have vou Itad an arrclionrett.ic test l:etble,l ,
youl healiug (e.g.: infecrion. tinni(us. clischarge
etc.)'i
YEs fl NO
ffi
If YES, rvhen:
IES fl
If YES. ltlease rleroit:.
No Z arrd q,hele :

Have ),olr ever. had arr ear opel.atiou or. auy \9f!: Atr qn.en,er o.f ,,1,85,, lor e2_e6, "IIORE
e7, *llOnf THAN 2
other. THAN ONCE .4 YEAR" for
ttra.jol ollelatirtu tliar aftectecl youL hear.insr
HOUR,S PER IYEEI{,' for
::1'-. f
If YES. pleale cterail.
No A BAND/,IYNIPHONI, OR(HE,sixe"
eB, ,R2(,li
fir e9 qnd its,
slgni/icttrtce fio,t: it,dlcote
01 hoy, tl,e lest results tvil.l
Have you .,u.,. ,nt.ul;;.;;;" r*i,rl, be inlerprelcrl. eucstion 10, Il and l2 ore ,nent,t
to
iujectious)rhat al'fecrecl your hearirrg,T re.ll.ect u susplciort t{ u pre-exisling hearing
disanler
):!l
If YES.
fl
lrlease <[erail.__
Nb Z nrtd the worker,s knowlerlge nboilt oiirliou,etri,
lesling.
(e.g.: chainsa,,v. tir.ecracker.ii.
ruot0lcvclesX
NORN,r..\r. fzl .{RNORI\IAr- I I

YES tl Ii YES. 1;lease rlerail:

IIYES. rvhat kind: C.4(itION: 'fhe ottcliotnetric testl,tg shail bc 0b0rted
arrd how often :
rr.rttl rescheduled ( nn1, sigttiliiutrt abnorrntliq,
Any faruily histor.y of hear.irrg lo.s.siclisor.rler.s?
delecled in lhe t,isuul exautinotiotr of lhe eor
I:l f]
If YESj, please cletail:
NoZ (e.9.: ac:tltte eor fisc,harge/excessitte certtmeu/ u,crx
i.nrpacllort etc.). ,4 referrat to fl (loctor
.for .ftttlrcr
ittlervenlion ,nay be ilecc;sortt belore ripeuting ttrc
Do 1,1'111 0ttend l)isllt clrrbsilnbsictiscolheqrres or. lest.
popi'l'ock corrcelts',,
NE\rER T_l ON(:EAYEAR
Lf NOTE: Pleose exptoitt cletrl.y: tl,e oiliiotnetric testittg
THAN ON('E ,{ YEAII A procedure (o the worker. 'I'ttis
N,{ORE lbrm i.s to be cortpilei
rpillt lhe audiometric report
for ret,iett, lhe OHD. b,
Do yorr usc: a persoual stereo (e.g.: rvalkniani
lPr:cl)'l

):lJl,^- 2 r{oLI*s pr,R *FEK tr SIGNATURE:

\,IORE TTIAN 2 HOIJRS PER \\JEE:K

T- NAi\{r, 3%1 €6a t
lAdaptt:d.l)oru. AtDt(\. ,4 of IS() .lig-9. .t009 (E))

b1
 s
STEP 1: lD (To be c
KLINIK ESPLANAD SIPITANG SDN BHD (1185815-D)
Lor
12, slPlrANG

Collecto
PLAZA,89850 stprrANc SABAH. No rEL: 087B22B5B

KES
Enrployee name I
SPECIMEN ID NO.: I Atiix Spccirnen lD herc
Employee NRIC/lD No.; 0-\ 467 Donor Photo lD verified , Ev., I No
Collection site name & addrcss:
MRO name: Reason lor test :

Employer name:
tr Pre-.mployment [--l Pre-placenrent
DER name: l-l Randonr [-l R"asonable suspicion/Cause
DER Tel. No.:
ER.*rn,o du,y I o,n.r,
sIE? 2: SPEC
D
Refer +^
^f^- to temperature strip, colour chart and test strips
POCT Results: lndicate tests
Specimen collection Non-observed
Observed AMPHETAMINES Remarks (if any):
AZEPINES
Tesr Kir Lot. No.:
Test Kit Expiry date: COCAINE

OPIATES (MOR
BAIIBITURA ES
MEl'HADONE
OXYCODONE
PHENCYCLIDINE
PROPOXYPHENE

I certi0r.46at I have point of collection testingon the above named incliviclual in accordance with the proceclures establisheri
b1,the Cornp,r*
Policy, and that I qualified to operate the lesting device(s) identified, and that the results are as recordecl.
DR FAIZUL BIII JALAI.

of collector Date
Q rlJ!4,
)ar(day/month/year) llmmiilr
SOI
,,,,;;;;;;;i;;;|6,i;)ui,i,","1'iT'ii,1,,,

i tamper'evidenl in my presence; and that the information provided in this form and on the label aftlxed to the specimen is correct.
9
tt
",-'"btZ-S0O{tQ6
Signature ot'donor Date \day/mont/year) Donor's Namq
, Donor'sTet. No.: t Date olbirth
'
: lO / qe (day/nonth/year) .\ i t fade
STEP 4:CHAIN OF CUSTODV
to taOoratoryl
I certit,v that the specimen giuen to m. Uy ttre Oor,.,r iA.ntin"A i,, tt., i
rvith the Company Drug and Alcohol policy and procedures.
Specimen bonle(s) released ro: (name of courier service)

l-l _ _(anr/pm,)
:# , ' ,?utqa'Yzl'o!*zx"l rin"
-

STEP 5:ACCESSIONl
primary specimen bottte i.al
I .Laboratory i
:
(lf seal not intact, enter remqrks in Step 6)

t--=---:!El3!!I9-ql-accessroner
i

Darc (dav/ntonth/vear) Accessioner's Name

STEP 6: CO
;o Negative o Re.iected tbr Testing
tr Adulterated o Substituted o lnvalid result
inPositiveftlr: !Arnphetamines DCocaine trBenzodiazepine DMDMA trCannabinoicls DOpiares !Orher:
' Rernarks (if any):_

t/
Signature of Certilying Technician/Scientist Oate (dry/^*tlr/y*0 Certifying Technician/Scientist's Nanre

DRUG TESTING CHAIN OF CUSTODY FORM