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Medical Screening Form

This 2-page medical screening form collects general information and medical history from candidates for an induction training session at Duqm Refinery and Petrochemical Industries Company. Information includes the candidate's name, address, contact details, occupation, return date to Oman, and observations from a physician. Candidates are asked if they have any fever, cough, difficulty breathing, or other COVID-19 symptoms. The form is to be completed by a nurse or physician and remains confidential.

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ibrahim
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406 views2 pages

Medical Screening Form

This 2-page medical screening form collects general information and medical history from candidates for an induction training session at Duqm Refinery and Petrochemical Industries Company. Information includes the candidate's name, address, contact details, occupation, return date to Oman, and observations from a physician. Candidates are asked if they have any fever, cough, difficulty breathing, or other COVID-19 symptoms. The form is to be completed by a nurse or physician and remains confidential.

Uploaded by

ibrahim
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Duqm Refinery Project EPC Package One 10121

Medical Screening form PAGE 1 OF 2

MEDICAL Screening Form


This is your medical screening form, to be completed prior the HSE
induction training session by Nurse or Physician. All information will be
kept confidential.

General Information
Candidate :
Name ______________________________________________________________________________
Address ______________________________________________________________________________
Contact phone numbers ______________________________________________________________
Birth date_____________________________________________________________________________

Physician and/or Primary Health Care Provider:


Doctor/Other________________________________ Phone _________________________________
Address _____________________________________ City ____________________________________

Occupation:
Position _____________________________________ Employer
______________________________Civil ID No : _________________
Address ______________________________________________________________________________
Phone ________________________________

Return Date to Oman _____ /_____ /_____


Observations______________________________________________________________
__

Do you know of any possible or confirmed case of infection by coronavirus


near you?
Yes No
If affirmative, specify:
Confirmed Investigated
MEDICAL INFORMATION
YES NO
Fever (________oC)
Cough
Myalgia
Throat ache
Chills
Difficulty to breath
Other breathing problems
Other symptoms

This document is property of Duqm Refinery and Petrochemical Industries Company. Page 1 of 2
Its reproduction without previous permission in writing is strictly forbidden.
Duqm Refinery Project EPC Package One 10121
Medical Screening form PAGE 2 OF 2

Name of Physician/nurse: _____________________ Sign__________________


Date: _____________
Name of HSE Manager
:_________________________Sign:___________________Date:____________

This document is property of Duqm Refinery and Petrochemical Industries Company. Page 2 of 2
Its reproduction without previous permission in writing is strictly forbidden.

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