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POSITION NOMINATED : CAMPBOSS

NAME : SUKAR ANAK BUNDAN

DATE OF BIRTH : 18.12.1968

HOME ADDRESS : RUMAH RAMBA, SUNAGI LIAM, BAKONG, 98050, BARAM SARAWAK.

CURRENT POSITION HELD : CAMPBOSS

NATIONALITY: MALAYSIAN

HOME TEL. : -

RELIGION : CHRISTIAN

RACE : IBAN

MARITAL STATUS : MARRIED

CONTACT TEL.: 011-2503 4109

NO. OF CHILDREN : TWO (2)

QUALIFICATION : SIJIL PELAJARAN MALAYSIA

SKILLS : MICROSOFT OFFICE

EXPERIENCES :

1) COMPANY :BUNGA CEMPAKA


YEAR :12/10/2015 – 11/2/2019
POSITION :CAMPBOSS

2) COMPANY :OSM SHIP MANAGEMENT PTE LTD


YEAR :21/7/2013 – 12/8/2015
POSITION :CAMPBOSS

3) COMPANY :AJANG SHIPPING SDN BHD


YEAR :21/5/2009 –11/3 /2013
POSITION : COOK AND BAKER
4) COMPANY :MARCO POLO HOTEL
YEAR :2005 - 2008
POSITION :PASTRY CHEF

5) COMPANY :SHERATON HOTEL


YEAR :2002 - 2005
POSITION :CHEF DE PARTIE

6) COMPANY :SHANG RI LA TG. ARU RESORT


YEAR :1996 - 1999
POSITION :COMMIS I

7) COMPANY :MERDEKA SUPERMARKET


YEAR :1994 - 1996
POSITION :ASST BAKER

REFEREES : 1) SHAHNAN HASAN AZIZ (BORNEO GEARS SDN BHD)


HP NO.: 016-666 8043

2) MARIANI SAGAP (BORNEO GEARS SDN BHD)


HP NO.: 013-892 2868
F.l-W Certificate htt ps ://rnysds. petronas. colx/worker/cefi i flcate/45 a9 I 4ea-00'19-'

Cert No:07950077

OFFSHORE AND REMOTE ONSHORE MEDICAL FITNESS CERTIFICATE

A: Personnel Data
18 Dec 1968
Full Name: SUKAR ANAK BUNDAN DOB:
ID No: 681218135677 Tel No: Occu CAMPBOSS

Date I May 2019 0.45.27

B: Type of Examination lnitial/ Renewal

C: of Evaluation
" G General Work (Other than specific job)
, S1 Catering Crew
52 Confined Space Worker
53 Crane Operators
54 Electrical Worker
55 Ernergency ResPonse Team (ERT)
SO Respirator Protective Equipment User

57 Working at Height
V.1 Visitor

D: Fitness to Work Status


Fitness to work for Offshore
The above personnel have been assessed tn accordance to the "Guidelines on Medical Assessment of
Remote Onshore Workers" and the fitness to work status for evaluation listec in Section c is/are as follows.

" Fit with no restrictions. Valid until (dd/mm/yy) 6 May 2021

Fit with Validity Restriction Only (dd/mm/yy)

Task Restriction (lf any)


The employee is flt for above work but should avoid the following tasks
Work near moving machinery or sharp edges Working at height

Operate motor vehicles or heavy machinery Pull push carry we ght over .. KG

Use a respirator Others (Specify):

Repetitive twisting of valves or wrenches


These task restrictions are Permanent These task restrlclions are Temporary

Not Fit To Work

E: Approved Medical Examiner's Details


AME Name: SE ENA IVART HAN KAN DI KT LLUVALAPP I L (P I\I U/PETFI )

AME No: t\tPll A[,1E079

Address: Lot 512, Ground Floor, Pelita Commercial Centre, l\,{iri, Sarawak l\4iri, Sarawak Sarawak
Tel: 085438068 Date: 9 MaY 2019 8 59:8

NOTE: MpM does not recognize this physical form as reference of medical fitness status for OSP card issuance.

Dr. Seena Ml( (MlYa:dO94)


Klinik Dr Cheu Sdn Bhd (666433-D)
Lot 512, Pelita Commercial Centre,
!8000 Miri, Sarawak, Malaysia.
T tt: 085-438068, 016-3398058 AME
Emril: secn:.kcheu@gnrail 079
-

Revision 4.0

FORM C _ OFFSHORE AND REMOTE ONSHORE MEDICAL ASSESSMENT FORM


sEcTtoN 1 -To BE coMpLETED By EMPLOYEE (PERSONAL INFORMATION, HEALTH DECLARATION AND CONSENT)

A" Worker Details

Name
Vt ttco, ht B,r,rrAorn NRIC /Passporl b +l( - \e, "q L
Age

Company & Address 0neo tv1 0ceupation tu/h U)adq


Race \
Date of examination Mobile phone: t\ aee 4 (e
Sex Male Female
Place of examination

B. Type of examination
E lnitial/Renewal as
tl Return to work

C. Type of Evaluation for Offshore & Remote Onshore (As per Employer Letter/lnstruction)
tl G General work (Other than Job Specific)

n Sl Catering Crew tl 55 Emergency Response Team (ERT)

Ll 52 Confined Space Worker tr 56 Respirator Protective Equipment User

D 53 Crane Operators tr 57 Working at Height

tl 54 Electrical Worker il Vl Visitor

This eonsent Form is introduced for the purpose of eompliance with the Personal Data Proteetion Act 2010.
: understand that:
1) Klinik Dr Cheu SB processes personal data of individuals for, amongst olhers:
(a) clinical evaluations for medical surveillanee and fltness to work assessments; and
(b) vaccinations
2) The personal data processed includes.
(a) my basic personnel data (e.g. name, date o{ birth, gender, addressl;
iUi mbOical surveillance and fitness 1o work nominatio-ns related toof my work, schedules. assessment outcomes (fiVunfii/other and
restrictions) and status, not the results. received/ not-received my laboratory test results; and
(c) specific medical data resulting-offrom my examinations, questionnaires, other visits and tests.
3) The piocessing of medical Oata inOividuals is performed by Klinik Dr Cheu SB staff. Klinik Dr Cheu SB uses my personal
information tor the following purposes:
(a) to assess my fitness to work;
(b) to recommend work restrictions and job accommodations, \
(c) for assessment and treatment purposes;
Ministry
iO) for compliance with occupational health and safety laws. includrng the requirements of MPM and its PACs or Malaysian
of Health ("MOH"); and / or lnsurance Companies
(e) on an anonymous.basis for statistics, health and safety programme improvements. scientific studies and research.
4) Only on a need to know basis, Klinik Dr Cheu SB shares my personal data, with:
(a) other health professionals for assessment and treatment purposes; and/or
in) Occupailonai heatth and safety authorities such as DOSH or MOH, as required by iaw and lnsurance companies.
5) bnty on a need to know basis, Klinik Dr Cheu SB may share my personal data with empioyer representatives, as necessary. to
inform them of Ktinik Dr Cheu SB's assessment of my medical fitness to work, which may include any work restrictions due to my
health condition. The need to know the inrormation is established through a responsibility to assist management in assignment in
work duties.
6) I acknowledge that my specific medical data under item 2(c) above rvill be stored in Klinik Dr Cheu SB Health record
system
7) This consent it valid unless il is revoked in writing
8) By signing I confirm that I have read the intbrmation in the attachment and give my consent to Klinik Dr Cheu SB to collect,
process, use, and store my personal data as described above.

Signature:
(rc* nr 4\4 Fund c^rr Date. +/oc)v

Nrte: lr.4PM AME shall enter the FTW Status into Ii/PM E-Reporting System (tvlySDS) and retained a record for future reference.
Revision 4.0

D0 YOU HAVE 0R HAVE YOU HAO : (Tick 'Yes' or'No')

Deseription Description N
Deseription Y N N

l.Sinus trouble 22.Cancet Have you ever been:-

2.Neck swelling / gland 23.Heart disease 43.Rejected for employment or insurance a-


3 Difficulty in vision 24.Rheumatic fever 44.Awarded benefits for lndustrial injury/ illness

4,Any ear discharge 25.Abnormal headbeat 45.Treated for problem of mental condilion

5,Bronchial Asthma / Bronchits 26.Hicrh blood pressure 46,Treated for problem of alcohol or drug ---1

6.Hay fever / Other allergy 27.Stoke 4T.Exposed to toxic substances or noise

7,Any skin trouble 28.Serious chest pain WOMAN ONLY, Have you ever had:"

Iu berculosis 29.Any blood disease 4S.Abnormal Pap smear

9 Coughed / Vomited blood 30.Painful passage of urine 49.Any gynecological condition / treatrnent

10.Severe abdominal pain 3l.Blood in urine 50.Are you prEnant

1 l.Stomach Ulcer 32.Diabetes Will you be doing any of these specific activities;

1 2,Recurrent indigeslion 33.Headache / Migraine 5l,Crane Operators

I 3.Jaundice or hepatitis 34.Dizziness / fainting 52.Users of Breathing Apparatus

I 4.Gall Bladder disease 35.Epilepsy 53.Catering Crew

1S.Marked change in bowel


36.JoinUspinal trouble 54.Confine Space Entry
habits
55.Working at Height
16.Blood in stools (motions) 3T.Surgical operation

17"Dental Problem 3B.Serious accident / injury Social History

18.Piles (Haemonoid) 39.Tropical disease 56.D0 you smoke?

19"Hemia 40.Fear of heights 57. History of drug abuse


58.D0 you drink alcohol?

20.Vancose Vetns
41. Fear of being enclosed li yes, amount per week? OC(
in a small space

42. Are you currently taking 59. Have you been medical disembarked from offshore
2'1.Lump in breast / arm pit Any medication? within the past 2 years? lf yes, please specify:

60. Other illness not mentioned above.


lf yes, please specify;

Have any of your family members suffered from the following?

6l.Diabetes 64.Heart Disease 6T.Hypertension

62.Tuberculosis 65.Epilepsy 68.St.oke

63.Bronchial Asthma 66.Cancer 69.Blood Disease

i tereby celify that the above information is couect to the best of my knowledge. I undersland that voluntary non-disclosure of any infornation required above is
a breach of PETRONAS ftness to work requtements and may rcsult in disciptinary action against ne, I fulher agree lo give consent lo the examining medical
proiessionals to dlsc/ose lhe resu/ts of this nedical questionnaire and associaterl nedical examination details to PETR)NAS, Petroleun Arrangement Contractor
(PAC) and my allmafters related to my Fitness to Wo* Offshore andlor Remote On.shore Worksile.

a.lr"
Signature:

Name sutlCr^- \t un} ,n


I t1
Date:

"le
Note: MP[/ AME shali enter the FTW Status into lr4PM E-Reporting System (MySDS) and retained a record for future reference.
Revision 4.0

SECTION 2 _ FOR USE BY EXAM|NING DOCTOR Name:


sulrs1/- tlr,tr_t D,+Fr,

HEIGHT WEIGHT BMI BLOOD


PULSE
vrsroN l, _
ois1a1^ p.Near L COLOUR BLOOD

,
(l'4nt1 ([ilogram) (Kg/m,) PRESSURE Coffrcled iwtt) WIY VISION GROUP
twv w >a 1o [* uncorrected
W12[+V0A N' F{} rru tbrvp,
N A DESCRIPTION tu'IEDICAL EXAMINATI0N - Detail of findinos
1 Eyes & Pupils

2. Ear/Nose/Throat

3 Teeth & Gum

4. Mouth

5 Respiratory

6. CardiovascularSystem

7. Abdomen

B, Hernial Orifices

L Extremities

1 0. i\4usculo-skeletal

?'ru 1l?,
1 1. Skin & Varicose Veins

12. Neurological
'13 Breasts

14 Anus & Rectum

15. Genito-Urinary Systems


,]6.
Others

N A TEST ,TION FINDINGS


1. Complete Blood Count

2. BUSE (?
3 Serum Creatinine O- V"'
4. Fasting Serum Lipid

5 Fasl ng Blood Sugar (HBA1c if indicated)

6 Urinalysis

' Urine Drugs

a. Amphetamine
b. Benzodiazepines
c.
d,
Cannabis
N4DMA tv-vh\rve
e. Opiates
f. Cocaine
8. Audiometry

9 Chest X+ay

10. ECG (40 years and above or clinicalty


indicated

11 Spirometry (if clinically indicated)


12. Others

N=Normal A=Abnormal

N4EDICAt VALiD Foi U ntil 6 oc) Shortened because of


RESIRlCTED For

f] uNFtr be.ause of
r$/

Signed:
nr. S MX (MMC a.0!1) @
hru 5.a tha (566.33-D) #sotrss
Commcrclel Ccntrc,
tiiri, lartral, h{rlrYrlr. -^Pt1t-rE
Irr: lr 5..lalCl, Cra.fltt0aS
trlore: l,rPtrt A[4E shltke...r rhc radetlt0dlfiU t{/?#Ap6fi[8 System (MySDS) anc a