Scribd
Upload
85 views

MPPC Health Indeminity Form

This health declaration form is for the Malaysia Public Policy Competition 2014 and collects information about any pre-existing medical conditions, drug allergies, or prescribed medications from participating individuals. It informs that any medical information provided will remain confidential and only be used internally, but may be disclosed to a doctor in the event of a medical emergency. Participants are asked to disclose details for any medical issues and sign the form, which team leaders must then submit together by August 4th, 2013.

Uploaded by

michaelforkcs
Copyright
© © All Rights Reserved
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
85 views

MPPC Health Indeminity Form

This health declaration form is for the Malaysia Public Policy Competition 2014 and collects information about any pre-existing medical conditions, drug allergies, or prescribed medications from participating individuals. It informs that any medical information provided will remain confidential and only be used internally, but may be disclosed to a doctor in the event of a medical emergency. Participants are asked to disclose details for any medical issues and sign the form, which team leaders must then submit together by August 4th, 2013.

Uploaded by

michaelforkcs
Copyright
© © All Rights Reserved
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/ 2

MALAYSIA PUBLIC POLICY COMPETITION 2014

HEALTH DECLARATION FORM



NAME : _______________________________________

TEAM NAME : _______________________________________

NRIC : _______________________________________

Conditions *Yes/No
1
Do you have any pre-existing illness or suffer from any
allergy? E.g. asthma, diabetes, epilepsy, hernia, dizziness,
circulatory problems, heart condition, high blood pressure,
rheumatic fever, stroke, high cholesterol, palpitations,
murmurs and/or pains in chest?


If yes, please specify:

2 Do you have any drug allergy? *Yes/No If yes, please specify:

3 Are you taking any prescribed medication? *Yes/No
For items marked with *, delete where inapplicable
If yes, please specify:


All information will not be disclosed and shall only be circulated internally for administrative
purposes. If you have answered YES to any of the questions above, please provide details. In the
event of medical emergencies, this form would be provided to the doctor.

Participant Name: _____________________________
Participant Signature: _________________________________
Date: _______________________

*Kindly fill up and pass to your team leader who will then submit this form by the 4th August 2013
in a SINGLE email.

You might also like