Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Personal Information

  • Full Names & Surname

  • ID or Passport number:

  • Occupation:

Medical

  • Type of Medical Examination Required:

  • Booking is confirmed for:

  • 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?

  • Signature of Tharisa Minerals Official

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.