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    Consent Form - Employer

    Uploaded by

    Shankarr Kshan
    This document is a consent form for a foreign worker to undergo medical screening in accordance with FOMEMA requirements. It authorizes a specific doctor to conduct tests including blood and urine tests and a chest x-ray. It also allows the disclosure of health records and information to relevant authorities including FOMEMA, the Ministry of Health, Immigration Department, and the worker's employer. The worker confirms whether they have taken any medications in the last two weeks and provides their last menstrual date. The form is signed by the worker and witness by the examining doctor.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Consent Form - Employer

    Uploaded by

    Shankarr Kshan
    2K views1 page
    This document is a consent form for a foreign worker to undergo medical screening in accordance with FOMEMA requirements. It authorizes a specific doctor to conduct tests including blood and urine tests and a chest x-ray. It also allows the disclosure of health records and information to relevant authorities including FOMEMA, the Ministry of Health, Immigration Department, and the worker's employer. The worker confirms whether they have taken any medications in the last two weeks and provides their last menstrual date. The form is signed by the worker and witness by the examining doctor.

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    This document is a consent form for a foreign worker to undergo medical screening in accordance with FOMEMA requirements. It authorizes a specific doctor to conduct tests including blood and urine tests and a chest x-ray. It also allows the disclosure of health records and information to relevant authorities including FOMEMA, the Ministry of Health, Immigration Department, and the worker's employer. The worker confirms whether they have taken any medications in the last two weeks and provides their last menstrual date. The form is signed by the worker and witness by the examining doctor.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2K views1 page

    Consent Form - Employer

    Uploaded by

    Shankarr Kshan
    This document is a consent form for a foreign worker to undergo medical screening in accordance with FOMEMA requirements. It authorizes a specific doctor to conduct tests including blood and urine tests and a chest x-ray. It also allows the disclosure of health records and information to relevant authorities including FOMEMA, the Ministry of Health, Immigration Department, and the worker's employer. The worker confirms whether they have taken any medications in the last two weeks and provides their last menstrual date. The form is signed by the worker and witness by the examining doctor.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    FOREIGN WORKER CONSENT, AUTHORISATION

    AND DECLARATION FORM


    This is to confirm that I, _______________________________________________________
    (Name of Foreign Worker)

    Workers code ________________________ passport number _____________________


    (Workers code)

    (Passport No.)

    hereby irrevocably consent and authorise Dr. _________________________________


    (Doctors Name)

    of _____________________________________________ to:(Name of clinic)

    i.

    carry out a medical examination on me including the testing of blood


    and urine and the taking of chest x-ray as required by the FOMEMA
    screening programme, and

    ii.

    disclose my health report / records and any other health information to


    FOMEMA Sdn. Bhd., the Ministry of Health, the Immigration Department,
    employer and any other relevant authorities, as and when it is required to
    do so.

    I also hereby confirm the following:


    i.

    I have not taken/ taken * (if taken, please specify) any medication / drugs
    within the last two (2) weeks,
    (a)_____________________ (b)____________________(c)_____________________

    ii.

    My last menstrual period was on ____ / ____ / _______ (DD/MM/YY).

    _____________________________________
    Signature or thumbprint of Foreign Worker

    ____________________________
    Date

    Witnessed by:
    ________________________________________
    Signature of Examining Doctor

    __________________________________
    Clinics Stamp

    ____________________________
    Name of Examining Doctor

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