PDO Medical examinations specification SP1230

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.