Scribd
Upload
2K views

Consent Form - Employer

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.

Uploaded by

Shankarr Kshan
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
2K views

Consent Form - Employer

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.

Uploaded by

Shankarr Kshan
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 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

You might also like