PDO Medical examinations specification SP1230

Petroleum Development Oman LLCRevision: 3.0Effective: 16 Apr 20079.8 Appendix H (Form SQ4): Catering and Food Preparation - ScreeningQuestionnaireEmployee DataLast NameDateFirst NameI.D No. Tel # OccupationThis questionnaire will help identify if you have any health condition which may need a more detailedmedical assessment as part of your fitness to work determination. If you have any queries pleasecontact your doctor or local Health Services staff. All information provided on this form and duringconsultations remains strictly confidential.Do you have any medical condition that you believe may affect your ability to handle foodsafely? (Answer “yes” if you do not know)Y / NHave you been in contact with anyone with any infectious disease in the past 12 months e.g.tuberculosis, typhoid, paratyphoid, or enteric fever?Y / NDo you have any skin problems (on arms, hands or face) that require treatment or affect yourability to wear gloves?Y / NDo you have any history of recurrent diarrhoea or other bowel problems?Y / NHave you suffered from a runny ear or chronic ear infection in the past year?Y / NHave you ever previously been advised that you should not prepare or handle food?Y / NThis form will be forwarded to the healthcare provider. If you answered “yes” to any question youshould seek a medical opinion from medical personnel on site before continuing to prepare food atwork.Declaration: I, ___________________________________________________________________ (PrintName) certify that to the best of my knowledge the above information supplied by me is true and correct.Signature:__________________________Date: _________________Page 58 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.