PDO Medical examinations specification SP1230

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Petroleum Development Oman LLCRevision: 3.0Effective: 16 Apr 20079.4 Appendix D: Questionnaires and Evaluation FormsForm Uses CommentQ1 Breathing apparatus first evaluationCrane drivers all evaluationsMedical historyquestionnaireEmergency Response Team all evaluationsProfessional driver all evaluationsRemote location all evaluationsE1 Breathing apparatus first evaluationCrane drivers all evaluationsEmergency response team all evaluationsProfessional driver all evaluationsRemote location all evaluationsE2 Statement of fitness for work completed byphysicianMedical physicalevaluation form –complete only theexaminationsindicated in therelevant protocolWhere writtencertification required.(An IT based record offitness to work is anacceptable alternative)SQ2 Breathing apparatus screening When further evaluationSQ3 Business travellers screeningSQ4 Catering and food preparation screeningSQ4a Catering and food preparation -return to workafter illnessSQ5 Epworth sleep apnoea screeningEX4 Group A transfer adultEX3 Group A transfer childEX2 Group B transferis required followingcompletion of ascreening questionnaire,the details should berecorded on Q1 and E1forms. The content willbe as clinicallyindicated for the issueunder investigation.Page 54 SP-1230 : Specification for Medical Examination, Treatment & Facilities Printed 25-Sep-08The controlled version of this CMF Document resides online in Livelink®. Printed copies are UNCONTROLLED.
Petroleum Development Oman LLCRevision: 3.0Effective: 16 Apr 20079.5 Appendix E: Fitness to Work CertificateEmployee DataLast NameDateFirst NameI.D No. Age OccupationType of Medical EvaluationMark those applying A1 Aircraft refuelling A6 Emergency response team workA2 Breathing apparatus A7 Professional drivingA3 Business traveller A8 Remote location workA4 Catering and food preparation A9 Transfers – group A countryA5 Crane or forklift driving A10 Transfers – group B countryHealth Advisor Statement The above named person has been examined according to the statementslaid down in “Protocols and Guidance Notes on the Medical Evaluation of Fitness to Work”. At thistime their fitness to work status for the above tasks is as follows.Fit with no restrictionsFit with following restrictionsThe employee is fit for above work but should avoid the following tasksWork near moving machinery or sharpedgesWorking at heightOperate motor vehicles, foklifts or heavymachineryUse a respiratorPull push carry weight over Kg Repetitive twisting of valves or wrenchesAscend/descend ladders or stairsFlyingOther (Specifiy)These restrictions are PermanentThese restrictions are temporary untilTemporary Unfit until(date)(date)Permanently UnfitDate Signature Print NamePage 55 SP-1230 : Specification for Medical Examination, Treatment & Facilities Printed 25-Sep-08The controlled version of this CMF Document resides online in Livelink®. Printed copies are UNCONTROLLED.
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PDO Medical examinations specification SP1230

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