MEDICAL REPORT FOR FOREIGN WORKER photo

FOR EMPLOYMENT IN BRUNEI DARUSSALAM

(in accordance with The Infectious Diseases Order; Immigration Act and
Labour Act of the Statutes of Brunei Darussalam)

Accreditation no: …………………… Ref. no.:

……………..…………………
PART I: PERSONAL INFORMATION
(To be completed by the applicant)

1. FULL NAME: ………………………………………………………………………………….……..

(please underline surname)
2. SEX: MALE / FEMALE 3. DATE OF BIRTH: …………….. 4. PASSPORT NO: ……………………..

5. TYPE OF JOB APPLIED: …………………………………………………………………………………..………….

6. ADDRESS IN COUNTRY OF ORIGIN: …………..………………………………………………………………….

……………………………………………………………………….…………………………………………………….

7. NAME OF EMPLOYER / RECRUITING AGENCY: ………..……………………………………………………...

8. FULL ADDRESS OF EMPLOYER / RECRUITING AGENCY: ……………………………..……………………..

……………………………………………………………………………………………………..………………………

PART II: MEDICAL HISTORY

(To be completed by the examining physician)

Has the worker ever suffered from or experienced or received treatment for the following diseases and conditions? If
‘YES’, please indicate dates of detection and treatment received.

YES NO DATE/TREATMENT
1 HIV / AIDS *
2 TUBERCULOSIS *
3 EPILEPSY *
4 LEPROSY*
5 SEXUALLY TRANSMITTED INFECTIONS *
6 PSYCHIATRIC ILLNESS *
7 HEPATITIS B *
8 HEPATITIS C *
9 DRUG USE *
10 DIABETES MELLITUS **
11 HYPERTENSION **
12 CANCER **
13 BRONCHIAL ASTHMA **
14 HEART DISEASE **
15 KIDNEY DISEASE **
16 HEARING PROBLEM **
17 VISION PROBLEM **
18 PEPTIC ULCER **
19 MALARIA
20 OTHERS

* To be considered unfit if answered ‘yes’ to any of the items

**Fitness is up to the discretion of the attending physician; must indicate severity, complications and medications currently taken by the applicant
 PART III: PHYSICAL EXAMINATION AND INVESTIGATIONS
(To be completed by the examining physician)

Section A: General Physical Examination

1. Height: ______cm 2. Weight: _______ kg 3. Pulse: ___________ /min

4. Blood pressure : __________ mmHg (Systolic/Diastolic)

Present Absent
5 Chronic skin rash/sores on hands
6 Deformities of limbs
7 Anaemia
8 Jaundice
9 Lymph node enlargement
10 Hearing impairment
11 Vision test
Unaided
Aided
Colour blindness

Section B: Systemic Examination

Normal Abnormal
1 Cardiovascular System
1.1. Heart Size
1.2. Heart Sounds
1.3. Other Findings ___________________________

2 Respiratory System
2.1. Breath Sounds
2.2. Other Findings __________________________

3 Gastrointestinal System
3.1. Liver
3.2. Spleen
3.3. Kidney
3.4. Is there any abnormal swelling? (YES/NO) Indicate if ‘YES’

________________________________________________________

3.5. Rectal Examination

4 Central Nervous System Normal Abnormal

4.1. General Mental Status
4.2. Speech
4.3. Cognitive Function
4.4. Motor power
4.5. Sensory
4.6. Reflexes

5 Genitourinary System Yes No

5.1. Discharge
5.2. Sores / Ulcers
 Section C: Laboratory results and X-ray findings

Negative Positive
1 Blood
1.1. HIV Antibody #
1.2. HBsAg #
1.3. HCV #
1.4. VDRL/ TPHA #
1.5. Malaria Parasite

If positive for malaria, give appropriate treatment and then repeat 1.5
Date when blood test for malaria parasite is found negative after treatment: ____________________________

2. Urine Examination
2.1. Colour: ____________
2.2. Specific Gravity: ___________
Negative Positive
2.3. Sugar
2.4. Albumin

2.5. Microscopic Examination: ________________________

2.6. Others: ________________________________________________________________________

2.7. Opiates #
2.8. Cannabis #
2.9. Methaphetamines #
2.10. Benzodiazepines #
2.11. Pregnancy #

Normal Abnormal
3 Chest X-Ray Report
(valid for 6 months) - UNFIT IF ANY ABNORMALITY IN THE LUNG
FIELDS are present)

4 Stool examination # [for those handling food] Negative Positive

Salmonella Typhii
V.Cholera
V.Parahaemolyticus
Shigella
E.Histolytica
Other enteropathogens (please state)

If positive for any of the above, give appropriate treatment and then repeat stool examination
Date when stool examination is found negative for all of the above after treatment: ______________________

5 Sputum AFB (if indicated) Negative Positive

6 ECG (if indicated) Normal Abnormal

7 Slit skin smear (if indicated) Negative Positive

# To be considered unfit if found positive/ abnormal

PART IV: VACCINATIONS GIVEN (IF APPLICABLE)

Vaccine Batch no. Given by

1. Typhoid/ Paratyphoid __________ __________ __________
2. Tetanus __________ __________ __________
3. Hepatitis B __________ __________ __________
4. Others (Please state) _________ _________ ________
 PART V: CERTIFICATION BY EXAMINING PHYSICIAN

I HAVE EXAMINED THE ABOVENAMED APPLICANT AND FOUND THAT HE / SHE IS FREE FROM THE
FOLLOWING DISEASES:
YES NO
HIV / AIDS

TUBERCULOSIS

MALARIA

LEPROSY

SEXUALLY TRANSMITTED INFECTIONS

HEPATITIS B

HEPATITIS C

EPILEPSY

PSYCHIATRIC ILLNESS

AND HIS / HER URINE IS FOUND NOT TO CONTAIN OPIATES / CANNABIS / METHAMPHETAMINES /
BENZODIAZEPINES.

SHE IS / IS NOT PREGNANT (IF APPLICABLE).

HE / SHE HAS / HAS NOT BEEN GIVEN THE APPROPRIATE VACCINATIONS (IF APPLICABLE).

HE / SHE IS FIT / UNFIT TO BE EMPLOYED IN THE JOB THAT HE / SHE IS APPLYING FOR.

I THEREFORE RECOMMEND THAT HE / SHE BE CONSIDERED / NOT CONSIDERED FOR EMPLOYMENT.

[IF NOT CONSIDERED FOR EMPLOYMENT PLEASE STATE THE REASON(S) BELOW]

________________________________________________________________________________________________

____________________________ ________________________
SIGNATURE DATE

NAME OF CERTIFYING PHYSICIAN: _______________________________________________________________

ADDRESS OF PHYSICIAN: ________________________________________________________________________

_________________________________________________________________________________________________

QUALIFICATIONS: _______________________________________________________________________________

OFFICIAL STAMP

(TO BE RETAINED BY THE EXAMINING PHYSICIAN)

 FOR OFFICIAL USE ONLY BY THE EMBASSY/HIGH COMMISSION/CONSULATE
OR REPRESENTATIVE OFFICE OF BRUNEI DARUSSALAM

Accreditation no: …………………….. Ref.no: …………………………………..

1. FULL NAME: …………………………………………………………………………….……..

(please underline surname)
2. SEX: MALE / FEMALE 3. DATE OF BIRTH: …………….. 4. PASSPORT NO: ………….………

5. TYPE OF JOB APPLIED: …………………………………………………………………………………...…..

6. ADDRESS IN COUNTRY OF ORIGIN: ……………………………………………………….……………....

…………………………………………………………………………………………………………………….…

7. NAME OF EMPLOYER / RECRUITING AGENCY: ..……………………………….……………………….

…………………………………………………………………………………………………………….…………

8. FULL ADDRESS OF EMPLOYER / RECRUTING AGENCY: ……………………………….……….……..

………………………………………………………………………………………………………….……………

I HAVE PERUSED THE ABOVE APPLICANT’S PRE-EMPLOYMENT MEDICAL DOCUMENTS AND FOUND
THAT THE RECORDS ARE / ARE NOT IN ORDER AND HEREBY ISSUE / NOT ISSUE AN EMPLOYMENT
ENTRY VISA.

VISA NUMBER ISSUED: ____________________________________________________________________

_____________________________ ________________________
SIGNATURE DATE

NAME OF OFFICIAL: ______________________________________________________________________

DESIGNATION: ___________________________________________________________________________

APPLICANT’S PHOTO OFFICIAL STAMP

(TO BE RETAINED AT THE ABOVE OFFICE FOR REFERENCE)

 MINISTRY OF HEALTH BRUNEI DARUSSALAM
MEDICAL CERTIFICATE FOR FOREIGN WORKER
(Please attach all results of investigations, X-ray and radiologist report)
Accreditation no:…………………………. Ref.no:
…………………………………………

1. FULL NAME: …………………………………………………………………………………………………

(please underline surname)
2. SEX: MALE / FEMALE 3. DATE OF BIRTH : …………………… 4. PASSPORT NO:……………………….
5. TYPE OF JOB APPLIED : ……………………………………………………………………………………………….
6. FULL ADDRESS IN COUNTRY OF ORIGIN :……………………………………………….…………………………
………………………………………………………………………………………………………………………………….
7. NAME AND FULL ADDRESS OF EMPLOYER / RECRUITING AGENCY…………………………………………..
………………………………………………………………………………………………………………………………….

I HAVE EXAMINED THE ABOVE NAMED APPLICANT AND FOUND THAT HE / SHE IS FREE FROM THE
FOLLOWING DISEASES:
HIV / AIDS
TUBERCULOSIS
MALARIA
LEPROSY
SEXUALLY TRANSMITTED INFECTIONS
HEPATITIS B
HEPATITIS C
EPILEPSY
PSYCHIATRIC ILLNESS
AND HIS / HER URINE IS FOUND NOT TO CONTAIN OPIATES / CANNABIS / AMPHETAMINES /
BENZODIAZEPINES
SHE IS NOT PREGNANT (IF APPLICABLE)
HE / SHE HAS BEEN GIVEN THE APPROPRIATE VACCINATIONS (PLEASE STATE IF GIVEN)

________________________________________________________________________________________________
HE / SHE IS FIT / UNFIT TO BE EMPLOYED IN THE JOB THAT HE / SHE IS APPLYING FOR.
I THEREFORE RECOMMEND THAT HE / SHE BE CONSIDERED / NOT CONSIDERED FOR EMPLOYMENT.

____________________________ _______________________
SIGNATURE DATE

NAME OF CERTIFYING PHYSICIAN:_____________________________________________________

ADDRESS OF PHYSICIAN:______________________________________________________________

QUALIFICATIONS:______________________TEL.NO:________________FAX NO:_______________

Official stamp Photo

VALID ONLY FOR 180 DAYS FROM THE DATE OF ISSUE