Medical Examination for Certificate of Fitness Booking Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Personal Information

• Full Names & Surname

• ID or Passport number:

• Occupation:

Medical

• Type of Medical Examination Required:

  Initial

  Periodical

  Exit

• Booking is confirmed for:

  Date

• Please ensure that you bring the following with you on the day of the examination:
  Copy of Exit Medical Certificate from previous employer ( if previously employed under MHSA)
  Copy of ID/Passport
  Any current medication that you are taking
  T-Shirt for the ladies (x-rays)
  Specticles (if prescribed)

• Note: Drivers & Operators
  BAC (Blood Alcohol Concentrate)
  TCH (tetrahydrocannabinol)
  CBT (Colour Blindness Test)

Approval

• This form will be requiered as proof of payment as agreed to by .......

• Approved?

  Yes

  No

• Signature of Tharisa Minerals Official

  Sign