PDO Medical examinations specification SP1230

Petroleum Development Oman LLCRevision: 3.0Effective: 16 Apr 20079.10 Appendix J (Form SQ5): Epworth Screening Questionnaire for SleepApnoeaEmployee 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 local Health Services staff. All information provided on this form and duringconsultations remains strictly confidential.How likely are you to fall asleep in the following situations?0 Would never doze1 Slight chance of dozing2 Moderate chance of dozing3 High chance of dozingsitting and readingwatching TVsitting inactive in a public place (e.g. theatre or meeting)as a passenger in the car for an hour without a breakLying down to rest in the afternoon when circumstances permitSitting a talking with someoneSitting quietly after lunch without alcoholIn a car, while stopped for a few minutes in trafficTotalIf you score a total of 15 or more you should seek advice from medical personnel on site before continuing todrive or operate machinery in the workplace.Declaration: I, _________________________________________ (PrintName) certify that to the best of my knowledge the above information supplied by me is true and correct.Signature:__________________________Date: _________________Page 60 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.