snamprogetti saudi arabia co. ltd.
ANNEX Q
FITNESS MEDICAL EXAMINATION
PROTOCOL J3
Recommended minimum protocol for Subcontractors
Pre-employment & Periodical
1. General Medical Examination
- Including Body Mass Index (BMI) and Eye examination (vision: Far/Near/Color);
2. Chest X-Ray Report or Spirometry;
3. ECG;
4. Audiogram;
5. Blood examination:
5.1 CBC (Hemogram + ESR);
5.2 Biochemical:
- Fasting Blood Sugar
- Fasting Lipid Profile
6. General Urine examination;
NOTE:
The form “Medical Report” that shall be used to draw up the medical examination reports;
The "Medical Fitness Certificate” that shall be used to issue the medical fitness status.
.
Period of validity of “Medical Fitness Certificate” is 2 years, if no other restriction or objectives;
The Health Certificate and medical report forms shall be duly filled and signed with official stamp of the
Physician & the Hospital and also the employee's signature wherever required .
Doc. n. FORM-COR-HR-HLT-040-E
MEDICAL FITNESS CERTIFICATE Rev. 03 26/09/16 Page 1 of 1
Ref. doc. OPR-COR-HR-HLT-001-E
MEDICAL FITNESS CERTIFICATE
issued in accordance with Oil & Gas UK Guidelines, Saipem Corporate Standards OPR-COR-HR-HLT-001-E, STD-COR-HLTCLI-001-I,
IMO and STCW Guidelines on medical examination
Full name (in block letters) Date of Birth Occupation
This Health Certificate is valid until: _____________
□ Fit □ offshore □ onshore
□ Fit with prescriptions and/or restrictions □ permanent □ temporary for months ……….
□ Unfit □ permanent □ temporary for months ……….
Specify prescriptions and/or restrictions ………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………
Applicant’s signature in the Doctor’s presence
Place Day, Month, Year
-----------------------------------------------------------
Doctor’s stamp and signature
Employer must provide the personal protective equipment specific to the activity
Doc. n. FORM-COR-HR-HLT-039-E
MEDICAL REPORT Rev. 03 07/12/2016 Page 1 of 3
Ref. doc. OPR-COR-HR-HLT-001-E
1. PERSONAL ANAMNESIS
Name in full Date of Birth Sex M F
Occupation Badge No. Blood Group Rh
Please tick box Yes No Details if “yes”
(including dates and duration and any other relevant information)
1. a) Are you at present under medical care or receiving treatment?
b) Are you currently taking medication, prescribed or not,
having injection, using an inhaler or have you recently done
so, or are you on a special diet?
2. Have you ever suffered from:
a) Fits, fainting, giddiness or any mental or nervous disorder?
b) Asthma, bronchitis, pneumonia or any other lung disorder?
c) Rheumatism, rheumatic fever, arthritis or any other disorder
of joints and muscle?
d) Chest pain, shortness of breath, palpitation, high blood
pressure or other disorders of the heart or circulation?
e) Indigestion, peptic ulcer, diarrhoea, constipation or any
intestinal complaint, hepatitis or other liver disorders, diabetes
f) Kidney, bladder o other genito-urinary disorders?
g) Any injury, operation, physical defect or deformity?
h) Any other illness not mentioned above?
3. a) Have you ever been a patient at a hospital, nursing home
or special clinic?
b) Have you ever had any medical investigation carried out?
4. Have you ever had any form of sexually transmitted disease
or is there anything about your lifestyle which could expose
you to the risk of AIDS or AIDS related condition?
5. Female only: Have you ever had any gynaecological or
obstetric problems?
6. Have you ever taken drugs other than prescribed by any
doctor?
7. a) Non-smoker: Have you smoked in the past?
b) Smokers: How much do you smoke per day? Cigarettes Cigars Pipes Number smoked
c) What is the average daily consumption of alcohol?
2. FAMILY MEDICAL ANAMNESIS
If living, age State of health If dead, age at death Cause of death
Father
Mother
Brother / Sister
Brother / Sister
Brother / Sister
I declare to the best of my knowledge and belief the answers to the above questions are true and complete. I confirm that I have checked and found correct any answers that are not in my handwriting. I grant
permission to take samples of blood, saliva and/or urine in connection with this examination. I understand that this statement will be forwarded to the Company’s Medical Department.
Applicant’s Signature DATE
(to be signed in the presence of Medical Examiner)
Doc. n. FORM-COR-HR-HLT-039-E
MEDICAL REPORT Rev. 03 07/12/2016 Page 2 of 3
Ref. doc. OPR-COR-HR-HLT-001-E
3. SUMMARY OF MEDICAL HISTORY OF MR. /MRS.
Has the applicant ever had or has now any of the following? If yes, give details in the summary description.
Please, tick box, whether normal or not Yes No Yes No
1. Ear infection / Sinusitis / Vertigo 8. Endocrine disorder
2. Nose, mouth or throat trouble 9. Hernia / Hydrocele / Piles / Fissures
3. Color blindness / Loss of vision 10. Fistula / Appendicitis / Varicocele
4. Frequent headaches / Fainting 11. Malaria / Tropical Disease
5. Epilepsy / Mental illness 12. Skin disease
6. Hypertension 13. Cancer or tumor
7. Diabetes mellitus 14. Allergy to foods / drugs
Remarks:
4. MEDICAL EXAMINER’S REPORT
If you answer Yes to any of the following questions, please give full details with any ascertainable cause as applicable
Please tick box Yes No Details if “yes”
8. Measurement & Physical Description
a) Measurements (to be taken in indoor clothing) Height: cm Weight: Kg
2
b) Please describe general appearance and build: BMI: Kg/m W aist Circumference: cm
c) Are there any signs of past or present over-indulgence
in alcohol, tobacco, or irregular lifestyle
d) Is there any enlargement of lymph nodes or thyroid gland?
e) Are there any scars of material significance?
9. Cardio-vascular System & Blood pressure
a) Does the heart appear to be enlarged?
If “yes”, do you consider this to be slight, moderate or marked?
b) Is there any irregularity of rhythm?
c) Is there any abnormality in the arterial pulse?
d) Are there any varicose veins?
e) Blood Pressure: (please record opposite) Systolic / Diastolic: Pulse Rate:
10. Respiratory System
a) Is there any abnormality in the shape and development of
the chest?
b) Are there any abnormal physical signs in the lungs?
11. Genito / Urinary & Digestive System
a) Is the urine test abnormal?
b) Is there any abnormal tenderness, enlargement or other
palpable abnormality in abdomen?
c) Is a hernia present
Is there any dental problem such as caries, recurrent gum
d)
and mouth infections, abscess etc.?
12. Nervous System
a) Is there any sign of disease in the central nervous system?
b) Is there anything to suggest a tendency to psychiatric
disorder?
13. Sense Organs
a) Is there any affection of the eyes, ears, nose or tongue
Vision Far Vision Near Vision Color Vision
Uncorrected OD OS OD OS Adequate
Corrected OD OS OD OS Defective
Remarks:
Doc. n. FORM-COR-HR-HLT-039-E
MEDICAL REPORT Rev. 03 07/12/2016 Page 3 of 3
Ref. doc. OPR-COR-HR-HLT-001-E
5. EXAMINATION RESULTS AND REPORT
X-Ray, ECG, Audiogram and Blood Urine Laboratory Examination Report
All examination results are to be attached. Please, indicate your remarks in case of abnormal results
1. Chest X-Ray Report (****)
2. ECG Report
3. Audiogram Report
4. Spirometry Report
5. Blood Examination Report (Please, attach the results of the following examinations or indicate here below the results):
1) Hemoglobin 10) MCV (*) 19) HDL Cholesterol
2) RBC 11) MCM (*) 20) LDL Cholesterol
3) ESR 12) MCHC (*) 21) Triglycerides
4) WBC 13) Platelet 22) Total Bilirubin
5) Neutrophils 14) Reticulocyte (*) 23) Direct Bilirubin
6) Lymphocytes 15) Hematocrit 24) Alkaline Phosphatase
7) Monocytes 16) Glycemia 25) AST (SGOT)
8) Eosinophils 17) Blood Urea 26) ALT (SGPT)
9) Basophils 18) Total Cholesterol 27) Gamma GT
6. Urine Examination Report (Physical, Chemical and Microscopy test results: Please attach the results of the following examinations or indicate
here below the results). Please indicate abnormalities (if Any):
7. Drugs (***), alcohol screening test Report (***):(Please attach the results of the following examinations or indicate here below the results):
1) Amphetamines 3) Cocaine 5) Methamphetamine 7) Alcohol
2) Benzodiazepine 4) Marijuana 6) Opiates
8. HIV Test (*)
9. Tine (Tuberculin test) (*)
10. HBsAg (**) HBsAb (**) HBcAb (**) HBeAg (**) HBeAb (**) HAVAb(**) HCVAb(**)
11. TPHA
12. Stool examination (*)
13. Pharyngeal plug test (*)
(*)Only if required (**) Only to the personnel who have never been vaccinated before or if expressly required
(***)Compulsory on pre-employment medical examinations and periodical examination for OFFSHORE and employees involve in Safety
Sensitive Positions (SSP). For all other employees depend on circumstances, national and international legal requirements.
(****) Chest X-ray is required on the first examination. Afterwards, the examining physician has the discretion whether to perform it or not,
based on physical examination, laboratory results, epidemiological situation and local laws and regulation in the country of origin or assignment.
6. OVERALL SUMMARY, ASSESSMENT AND RECOMMENDATIONS
The present Medical Certificate is valid until:
I have examined Mr./Mrs. and found him/her (tick the box)
FIT for (offshore/onshore) duty UNFIT for duty Pending
Examining Doctor’s Signature Date: _______________________
(Stamp, Signature, Name and address of the Physician)
