DOCTOR

Appendix 1

INITIATION OF APPEAL FORM

(Appeal is to be made within 2 weeks from the certification date)

MAHATO YOGENDRA
Name of Foreign Worker: _______________________________________________
W9EM 379135
Foreign Worker Code: __________________________________________________
BALQIS TEXTILES AND MANUFACTURING SDN BHD
Name of Registered Employer:___________________________________________

2 JAN 2018
Examination Date: _________________________
(The date when the above foreign worker was examined)
5 JAN 2018
Certification Date: _________________________
(The date when the above foreign worker was certified)

Disease / Condition: _____________________________________________

URINE SUGAR 3 + ---DIABETES MELLITUS
(The reason for the unsuitability of the above foreign worker at the time of certification)

Decision with regards to appeal by the employer for the above foreign worker?
(Please tick √ at “Accept” column if appeal is accepted and you wish to carry out further investigations or
tick √ at “Reject” column if you do not wish to proceed with the appeal.)

ACCEPT
REJECT (Please state the reason if you reject the appeal):

______________________________________________________________________

Checklist for Accepted Appeal: (Please tick √ for each column)

Appeal Form (Compulsory)

Commitment Letter (Compulsory)
Request for Audit of repeat CXR.
Date of CXR sent to Medical Dept.: _________
Further Investigations that need to be done: (Please state the investigations)

FASTING BLOOD SUGAR, HBA1C

_____________________________________________________________________

_____________________________________________________________________

Signature of Examining Doctor: _________________ Clinic Stamp: ____________

Name of Examining Doctor: _____________________________________________

DR.ANBARASAN A/L ARUNASALAM
(The examining doctor is the doctor who certify the above foreign worker)

D2EA 000106
Doctor Code: ________________________ Date of Appeal: ___________________
11 JAN 2018

(This form is to be filled up by the examining doctor when the registered employer submits an appeal. The
filled-up form is to be faxed to FOMEMA. Fax No: 03-27828773 / 03-27828774)

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 EMPLOYER

Appendix 4

APPEAL FORM
Date : 11 JAN 2018

To : The Appeal Committee

FOMEMA Sdn. Bhd.

Employer :
BALQIS TEXTILES AND MANUFACTURING SDN BHD

Correspondence Address :

Tel No : (H) (O) 03-60344707

(H/P) (Fax) 03-60344707

Name of Employee (Foreign Worker) : MAHATO YOGENDRA

Worker’s Code : W9EM 379135

Worker’s Passport no. : 07760955
Country of Origin : NEPAL

I BALQIS
________________________________,
TEXTILES AND MANUFACTURING SDN the employer of the above-mentioned employee who
BHDbeen certified unsuitable for employment after undergoing a medical examination at Clinic
has
____________________________________________________
MEDIVIRON , BANDAR COUNTRY HOMES RAWANG 48000 due to the following reasons
_____________________________________________________________________________________
URINE SUGAR 3+

I would like to request for a second medical examination to be conducted by the initial examining doctor.

I acknowledge that the decision of the Appeal Committee of FOMEMA Sdn Bhd shall be final and agree
unreservedly to abide by it. I undertake to hold FOMEMA Sdn Bhd harmless from any loss or liability
arising from this appeal including amongst other things like the spread of any infectious/communicable
diseases by the said employee and further agree to indemnify and keep FOMEMA Sdn Bhd and /or its
directors, shareholders and employees indemnified from any loss or liability arising from this appeal.

I undertake to bear any and all cost of this appeal and acknowledge that this appeal process may take up
to four (4) weeks from the time of its submission.

_________________
Authorized signature

Name : __________________

NRIC : __________________

Employer’s Stamp (For Company only): ____________

(This form is to be filled up by the registered employer and verified by examining doctor. The filled-up form
is to be faxed to FOMEMA. Fax No: 03-27828773 / 03-27828774)

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 DOCTOR

Appendix 5

ANBARASAN A/L ARUNASALAM

Dr……………………………………….
KLINIK MEDIVIRON BANDAR COUNTRY HOMES RAWANG
………………………………………….

Vice President of Medical

Medical Department
FOMEMA Sdn. Bhd. Tel: 03-27828777
(Attn:___________________________) Fax: 03-27828773 / 27828774

Dear Sir,

DECLARATION VERIFYING THE IDENTITY OF THE WORKER

MAHATO YOGENDRA
Worker’s Name: …………………………………………………………………………..
W9EM 379135 07760955
Worker Code: …………………………………Passport No.: ……………………………..

DR.ANBARASAN A/L ARUNASALAM

I, Dr. …………………………………………. (APC No. ……………………………)
38311 / 2017 of the above-
mentioned clinic and solemnly and sincerely declare that I have verified the identity of the above-
mentioned foreign worker with his/ her passport as well as checked his/ her height: …………..,
167 CM

weight:…………….
60 KG and other physical distinguished marks (if any) ………………………………….
……………………………………………………………………………………………………………...
I also declare that I have personally conducted further investigations on this foreign worker based
on FOMEMA’s appeal procedure.

I make this solemn declaration conscientiously believing the same to be true.

…………………………………..
Signature of Doctor

……………………………………. …………….....
Date specimen / X-ray taken Clinic Stamp

11 JAN 2018
Date of examination ……………

*Note: Please attach medical report/ details of medical examination

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 EMPLOYER

Appendix 6

COMMITMENT LETTER

Date : 11 JAN 2018

To : Vice President of Medical
Employer : BALQIS TEXTILES AND MANUFACTURING SDN BHD
Address :
Tel No : : (H) (O) 03-60344707
(H/P) (Fax) 03-60344707

Name of Foreign Worker : MAHATO YOGENDRA

Worker Code : W9EM 379135
Worker’s Passport No. : 07760955
Country of Origin : NEPAL

I/We BALQIS TEXTILES AND MANUFACTURINGthe employer of the above-mentioned foreign worker,
____________________________,
acknowledge that I/we am/are aware of his/her medical condition:
_____________________________________________________________________and
URINE SUGAR 3+ duly
undertake full responsibility for him / her.

I/We declare that in spite of the foreign worker’s medical condition described above, I/we wish to
employ/continue employing him/her as __________________________ and his/her duties are as
follows:-

1)___________________________________________________________________________
2)___________________________________________________________________________
3)___________________________________________________________________________

In light of the medical condition described above I/we confirm and assure FOMEMA that I/we will
not assign him/her any tasks that would aggravate the foreign worker’s medical condition
described above and put him/her/others health at risk. Additionally, I confirm that I/we will bear
any and all cost relating directly or indirectly towards the medical management of his/her medical
condition.

I/We confirm that FOMEMA shall not be held responsible in any manner whatsoever, arising out
of FOMEMA’s certification of the above named foreign worker as being suitable for employment
in Malaysia despite the medical condition described above. I/we further undertake to hold
FOMEMA harmless from any loss or liability arising from this decision and agree to indemnify and
keep FOMEMA from any loss or liability arising from this decision.

_________________
Authorized signature

Name : __________________

NRIC : ___________________

Employer’s Stamp (For Company only): ____________

(This form is to be filled up by the registered employer and verified by examining doctor. The filled-up form
is to be faxed to FOMEMA. Fax No: 03-27828773 / 03-27828774)

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Appendix 17

To : Consultant Radiologist of FOMEMA SDN. BHD.

From : ____________________
Date : _________________

1. Please find attached X-Ray film (s) of Foreign Worker:

1.1 Name :_________________________________
1.2 Worker Code :_________________________________
1.3 X-ray Film (s) dated :_________________________________

2. Reason for Despatch to XQCC:

Appeal

3. Request for comparison & audit x-ray film and reports:

1st X-ray dated :__________________________________________

2nd X-ray dated : __________________________________________

NOTE:

The filled-up form is to be attached to the X-ray film and also faxed to Medical
Department, UNITAB MEDIC Sdn. Bhd. (FOMEMA Sdn. Bhd.)
Fax no: 03-27828773 or 03-27828774