PDO Medical examinations specification SP1230

Petroleum Development Oman LLCRevision: 3.0Effective: 16 Apr 20079.9 Appendix I (Form SQ4a): Catering and Food PreparationScreening Questionnaire following illnessEmployee DataLast NameDateFirst NameI.D No. Tel # OccupationTo be completed by all designated food handlers on return to work followingAbsence due to ill healthAny period of gastrointestinal illness whether resulting in absence or notThis form will be forwarded to the healthcare provider. I f your answer is in any of the shaded boxes, you mustseek a medical opinion from local Health Services before continuing to prepare food at work.Please tick the appropriate box YES NOHave you suffered from vomiting, diarrhoea or a bowel disorder during the last7 daysAre you currently free from an infection of the skin, ears, nose, throat andeyes?Have you been in contact with anyone suffering from Enteric Fever, Typhoid orParatyphoidHealth declarationI am currently free from all of the above symptomsI am currently free of any skin rash affecting my hands forearms and faceI have been free from sickness or bowel disorders for 48 hoursDeclaration: I, ___________________________ (Print Name) certify that tothe best of my knowledge the above information supplied by me is true and correct.Signature:__________________________Date: _________________Page 59 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.