لائحة فحوصات اللياقة المهنية والأمراض غير المعدية

Occupational Fitness and Non-Communicable Diseases Examinations Regulation

In line with the principles and objectives of the National Occupational Safety and Health Policy issued by Cabinet Decision No. 328 dated 13/06/1442 AH, aimed at assessing and preventing hazards to reduce occupational injuries and diseases through the development of legislation, regulations, technical guidelines, programs, and any applicable organizational tools, and based on the powers and responsibilities of the National Council for Occupational Safety and Health as outlined in Article (3) of the Council’s regulation issued by Cabinet Decision No. 379 dated 07/07/1443 AH, and in accordance with the amended Labor Law under Royal Decree No. (M/5) dated 07/01/1442 AH, labor laws are fundamental in defining and regulating the relationship between workers and employers to protect rights. In line with what is stated in the law in Article 131 (repeated), Article 143, and Article 187 of the Labor Law regarding the mandatory medical examinations, this regulation has been prepared in cooperation with government agencies and in consultation with representatives of employers and workers, applying the best local and international standards and practices for medical fitness examinations in accordance with the requirements of the International Labor Organization and the World Health Organization, to clarify the mechanisms related to medical fitness examinations for all professions in the Saudi labor market. This aims to monitor and follow up on individuals’ health to enhance occupational health through pre-placement and periodic examinations for workers, thereby contributing to reducing workplace accidents and occupational diseases and improving working environments in the Kingdom of Saudi Arabia.

Article One

Regulation	Occupational Fitness & Non-communicable Diseases Examinations Regulation.
Council	The National Council for Occupational Safety and Health.
Minister	The Minister of Human Resources and Social Development.
First Official	The Minister, the Governor or Chief Executive Officer, the Chief Executive, the Supervising Secretary, or their representatives.
Employer	Any natural or legal person who employs one or more workers for a wage or whoever he authorizes in private sector establishments.
Worker	Any natural person, male or female, who works for an employer and under his management or supervision in return for a wage, even if he is away from his sights.
Employee	Any person who occupies a public civil office in the State or exercises its functions, regardless of the nature of his work or the name of his job, whether by appointment or contracting permanently or temporarily.
Establishment	Any project managed by a natural or legal person employing one or more workers in return for remuneration of any kind.
Professional fitness	It is the ability of the individual, physically, mentally, and psychologically, to perform the job or professional tasks assigned to him without resulting in harm to his health or danger to the safety of others or the surrounding environment, and this is determined based on an approved medical evaluation conducted by an entity specified in this regulation.
Occupational Safety and Health	Protecting the worker/employee from any hazard related to his work that poses a threat to his safety or health, including physical, mental, and social health.
Follow-up of occupational fitness	Determining changes in health status as a result of practicing activities and tasks that lead to exposure to certain substances at the work site, through a doctor specializing in occupational medicine.
Occupational medical examination	research surveys and clinical examination for the purpose of preventing occupational diseases.
Occupational Medicine	It is the doctor specialized in occupational medicine specialist/consultant, classified by the Saudi Commission for Health Specialties, and it is a branch of medicine concerned with the health and safety of workers in the workplace, and aims to prevent, diagnose and treat diseases and injuries associated with the profession.
Occupational disease	A disease that arises due to work in professions or economic activities that cause this disease and is not due to factors external to its work, provided that this disease is included in the schedule of occupational diseases in which these diseases are exclusively specified.
Non-communicable diseases	Also known as chronic diseases, are conditions that tend to be of long duration and result from a combination of genetic, physiological, environmental, and behavioral factors. The main types of NCDs include cardiovascular diseases (such as heart attacks and strokes), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma), and diabetes.
Profession	It is a work or job performed by an individual on a regular basis, and requires specialized skills and knowledge acquired through education or training and aims to provide a specific service or work in exchange for a wage or income.
Entity	Any ministry, government agency, authority, department, public institution, fund or the like, and any independent body with a public legal personality.
Competent Authority	Any entity involved in the implementation of the provisions of this Regulation or the related laws, regulations, and decisions.
High-Risk professions and environment	Occupations whose workers may be exposed, permanently or partially, depending on the duration of exposure and frequencies, when performing work tasks, to high-risk activities and operations – for example, but not limited to, construction sites, working in transportation services, or handling high-risk materials such as chemicals or ionizing radiation, which increases the likelihood of occupational disease or accidents that may cause death or result in serious injury or disability.
Hazardous occupations	They are those that increase the risk of injury or death of the worker due to working conditions, such as working in mines or at high altitudes or when exposed to multiple physical, chemical or biological hazards determined by the risk assessment.
Restricted Occupations	They are those that impose restrictions on the worker determined by law (statutory) and include periodic examinations due to impact on the worker’s health and safety or others in the workplace, or in public places or the surrounding environment, such as aviation, public transport, work in food handling and processing, seafarers, firefighters and others.
Preventive measures	All preventive measures that are implemented to reduce the expected risks and losses.
Long medical leave	The absence of the employee/worker from work for health reasons that prevent him from performing his job duties for a period exceeding eight consecutive weeks.
Hierarchy of control	It is a systematic framework adopted in occupational safety and health systems and is used to reduce exposure to risks in a hierarchy that begins with the most effective measures, which are removal, replacement, then engineering controls, then administrative controls, and finally personal protective tools.

Article Two

This regulation aims to provide a comprehensive framework for assessing the health and psychological fitness of employees/workers to ensure that they are able to perform their job duties efficiently and safely in line with national standards and best international practices, which are the following:

1- Reduction of work injuries and accidents and occupational diseases.

2- Enhance the physical and psychological fitness of employees/employees.

3- Ensure that employees/employees are able to perform their tasks safely and efficiently

4- Introducing the mechanism of pre-appointment/employment medical examinations and periodicity for high-risk practitioners.

5-Unify pre-appointment/employment medical examination forms, periodic examination and exceptional examination that suit each profession and provide comprehensive databases on the health status of all employees/employees.

6- Improve compliance with local standards and regulations and international conventions in the field of occupational safety and health.

Article Three

1- The provisions of this regulation shall apply to all employees in public entities, private sector establishments, and non-profit organizations, regardless of the type of contractual relationship or the nature of work, and include permanent employees, temporary or seasonal contract workers, trainees, people with disabilities, and workers under the remote work system, in any of the following cases: A- Before the start of the employment relationship when applying for employment, and it is required to pass the medical examination of occupational fitness before completing the appointment. B- Employees on the job in the following cases:

– After an occupational injury

– Upon return from a long medical leave

– When there are doubts about the ability of the worker / employee to perform his work

– If the job / profession requires a periodic medical examination in accordance with the approved forms attached to this regulation.

– Upon a change of occupation, if the worker/employee is transferred to a position or occupation that requires a different type of medical examination, additional tests shall be conducted in accordance with the approved examination forms set out in the Appendix to this Regulation.

– In the event of a change in the work environment, including but not limited to the permanent or temporary assignment of the worker.

– If new equipment, machines or devices are used. C- Upon retirement from work in case of exposure to materials with a long latency period during the period of work, such as asbestos or ionizing radiation.

2- The application of this regulation does not apply to medical examinations outside the scope of the job/profession.

Article Four

The first official in government agencies / civil public sector and the employer in private and non-profit sector establishments (or their delegates) shall comply with the following:

1- Verifying and ensuring that occupational fitness examinations are conducted and following up on his employees according to the approved forms and professions specified for them and making the necessary arrangements to enable the worker / employee to do so.

2- Provide the necessary resources to conduct examinations for its employees.

3- Notify the doctor specialized in occupational medicine of any exposures or risks that may affect the safety and health of the worker/employee during the practice of work, and the employer must refer the worker/employee to the competent doctor to ensure his health fitness.

4- Ensure that the worker receives appropriate health monitoring of health and safety risks to which he is exposed at work.

5- Work on creating health records within the standards of the Personal Data Protection System that include various documents containing the professional medical history of the worker/employee in his workplace, assessing risks and exposures in the workplace, and sharing them with relevant parties through the means approved by the Board.

6- Support compliance with the provisions of the Regulation.

7- Take all procedures and measures to organize work in accordance with the requirements of the regulation.

8- Do what is necessary to find alternative work if the worker’s job is medically prohibited, considering the following cases: A- In the event of changes in the employee’s health status or a new development in medical restrictions, the employer must reconsider the alternative work provided and update it in proportion to the health status to ensure the employee’s success in the new job while maintaining his health and safety. B- If the worker/employee is unable to fully perform alternative work tasks due to medical restrictions, the employer must provide the necessary adjustments to the working conditions, such as flexible working hours, part-time or any other arrangements to ensure that the employee continues in a safe and appropriate environment. C- If an employee’s health condition improves over time and they are able to return to their original employment, the employer must conduct a comprehensive assessment that includes a fitness check to restore the employee’s original job in line with their current health condition.

Article Five

Employees and employees are committed to the following:

1- Undergo the occupational fitness examinations required by the employer, in accordance with the requirements of this regulation, the approved forms, the nature of the profession under assignment, and in coordination with the concerned authority within the establishment.

2- Disclosure of occupational symptoms, injuries and diseases and providing any necessary health information according to the approved form.

3- Immediately notify the employer or his representative of any risks, defects or practices that may affect his safety or the safety of those around him within the work environment.

4- Inform the competent authorities of any fundamental violations committed by the establishment related to non-implementation of the requirements of this regulation, whenever this is proven to the worker and affects occupational safety and health.

Article Six

Any employee or worker may submit a report to the competent authorities regarding any violations committed by the entity or establishment related to the non-implementation of the requirements of this Regulation.

Article Seven

The occupational fitness examination form for the worker/employee is selected according to the following criteria:

1- Actual work.

2- Job description.

3- The physical, chemical, or biological substances hazards to which they are exposed.

4- The mechanism of exposure.

5- The level of exposure to physical, chemical, or biological substances or factors.

6- Duration of exposure to physical, chemical, or biological substances or factors.

7- Applying preventive measures and providing special equipment conforming to the standard specifications issued by the Saudi Standards, Metrology and Quality Organization regarding occupational safety and health to reduce exposure to materials in accordance with the relevant regulations and monitor adverse health effects.

Article Eight

The occupational fitness examination may not be used as a substitute for the implementation of individual or collective hierarchy of controls, and it is prohibited to rely on it as the sole basis for protecting the worker, except for the following cases:

1- Use the results of the examination to assess the effectiveness of control measures applied to practitioners, by measuring occupational exposure levels.

2- Use the results of the examination to support the decision to apply new or more effective preventive measures, whenever necessary, and the employer remains responsible for ensuring a safe working environment, regardless of the results of occupational fitness examinations. In all cases, the principle of gradual risk control shall be applied, so that engineering and administrative measures, isolation and ventilation techniques, and protective equipment are provided over medical or control means, considering medical examination as a means of monitoring, not prevention.

Article Nine

The types of medical examinations for occupational fitness are as follows:

1- Completion of the questionnaire attached to the regulation by the worker or employee.

2- Medical history by the doctor-in-charge.

3- General medical examination: A- Vital Signs Assessment. B- Clinical examination. C- Examination of sensory functions.

4- Laboratory and radiological tests.

5- Additional specialized examination according to the nature of the profession, according to the approved forms.

Article Ten

The mechanism for carrying out the tests shall be as follows:

1- Pre-appointment/employment medical examination: This examination is conducted on all candidates for jobs/professions and includes the analysis of medical history and history of exposure to occupational conditions, according to the approved forms according to the nature of the profession / job.

2- Periodic medical examination: Conducted at regular intervals according to the requirements of each profession/job, and the type and level of potential health risks, these periodic check-ups may be legally “restricted” such as working in aviation, diving, manufacturing and servicing food, firefighting, carrying weapons, handling explosives, radioactive materials, etc.

3- Exceptional medical examination: It is conducted when needed, such as an accident or a noticeable change in performance, or if the specialist doctor notices early signs of specific occupational diseases or the presence of a group of similar cases resulting from possible exposure to occupational hazards or exposure to toxic substances, or suspicion of using prohibited and narcotic substances, and the specialist doctor must ensure that the occupational injury or occupational disease is reported in the competent authority.

Article Eleven

The occupational periodic fitness medical examination consists of four integrated programs as follows:

1- Mandatory initial examinations: These are periodic basic examinations required for all workers in specific professions according to licensing and practice regulations, including: A- Compulsory Professional Fitness Questionnaire. B- Vital signs assessment. C- Clinical examination. D- Examination of the senses. E- Laboratory and radiological tests. The results of these examinations are part of the legally binding occupational health record.

2- Mandatory advanced examinations: determined based on the risk assessment or conditions of the working environments or added by the occupational medicine specialist based on other health indicators, including: A- Spirometry and respiratory fit testing. B- Aerobic fitness tests (oxygen-based exercises) depending on the nature of the tasks. C- Substance use testing. D- Job-mandated tests (e.g. tests related to infectious diseases).

3- Occupational fitness examinations according to exposure: The establishment must add examinations according to exposure to work hazards, such as chemical, physical or biological, to the list of examinations required for the profession and update this in its internal policy, in a way that does not contradict the list of compulsory and special examinations.

4- Optional advanced examinations: The supervising or licensed authority for the economic field, the first official or the employer may develop a special policy related to examinations and tests that are commensurate with the nature of work in the profession within the facility, including additional age-related preventive examinations such as glaucoma screening or those related to sex such as screening for breast, cervical or colon cancer in women, prostate or colon in men, or Substance use testing or behavioral assessments, in a manner that does not conflict with this regulation or the relevant national regulations, legislation, policies and regulations. The color-coded for the test levels is as follows:

(Blue) Occupational fitness examination according to exposure

(green) Mandatory advanced examinations

(Orange) Mandatory initial examinations

Article Twelve

Occupational fitness examinations for workers in high-risk professions shall be conducted in accordance with the requirements specified in the procedural manual for the organization of work in high-risk professions, and these examinations are divided into the following categories:

1- Medical examination of occupational fitness for hazardous professions.

2- Medical examination of occupational fitness for restricted professions. Medical examinations of occupational fitness included in the occupational fitness examination forms for high-risk professionals are subject to the color coding of the examination levels as described in the fourth paragraph of Article Eleven.

Article Thirteen

The results of the tests are dealt with according to the following:

1- Upon completion of the medical examination prior to appointment/employment, the result shall be as follows: A- “Fit to work” allowed to perform the profession / job for which he is nominated. B- “Fit to work with restrictions or considerations” required to be adhered to when practicing the profession for which the candidate is nominated, including the duration.

C- “Unfit to work” not allowed to practice the profession / job for which he is nominated (the duration of the time is determined by the professional doctor).

2- In the event that the requirements of professional fitness are not met after the periodic examination, the worker/employee is prevented from continuing to practice his profession and the supervising department must take the necessary measures to modify/change his profession, unless there is sufficient evidence proving his ability to perform his job duties efficiently and without risks to himself or others, through additional examinations or recommendations determined by occupational medicine specialist, and the employer has the right to exclude some cases, provided that the safety and health of the worker / employee is not affected after the approval of the committee and the worker.

3- In case of objection, the worker/employee or employer has the right to request another evaluation from an independent medical examiner.

Article Fourteen

1- The employer shall be obliged to inform the worker of the result of the fitness assessment immediately upon receiving the result from the service provider.

2- The worker or candidate for the job has the right to object to the result of the occupational fitness examination, of any kind, within a period not exceeding thirty (30) days from the date of official notification of the result.

3- Objections shall be referred to an independent committee formed in the secretariat of the Council, which shall review the medical file, examinations, and relevant technical reports. The Committee may request additional examinations or an impartial medical opinion from an independent professional examiner.

4- The Committee shall issue its decision within a period not exceeding fifteen (15) days from the date of receipt of the objection.

5- The decisions of the Committee shall be binding on the concerned authorities unless challenged before the competent authorities by law, and this shall not prejudice the worker’s right to resort to the competent judicial authorities in accordance with the relevant regulations.

Article Fifteen

The medical examination of occupational fitness must be conducted by a specialized team under the supervision of an occupational medicine specialist doctor accredited by the Saudi Commission for Health Specialties.

Article Sixteen

The team and the doctor specialized in occupational medicine are obligated to conduct medical examinations before appointment / employment, periodic examinations, and exceptional examinations for employees and employees, in accordance with the approved occupational fitness examination forms attached to the regulation. The standards specified in the forms must be adhered to and not modified or exceeded except after the approval of the secretariat of the National Council for Occupational Safety and Health.

Article Seventeen

1- Professional health records are confidential documents and may only be viewed by health care professionals in the facility or by the authorities concerned with conducting medical examinations, within the limits required by their duties, and in accordance with the provisions of the Personal Data Protection Law.

2- The medical records of employees/employees may be transferred when moving to another facility after obtaining written or electronic approval from them.

3- Strict procedures and measures shall be adopted to ensure the security and protection of information and technology to prevent loss, misuse, modification, or unauthorized access to the electronic system, in accordance with the controls of the National Data Governance Policy and the relevant regulations issued by the Saudi Authority for Data and Artificial Intelligence.

4- The employer is prohibited from accessing any medical details, and is limited only to knowing the final occupational decision regarding the worker’s ability to work, which includes: A- Fit. B- Fit with restrictions or considerations. C- Unfit. With a statement of restrictions or professional considerations, if any, without disclosing the diagnosis or private medical data.

5- The doctor specialized in occupational medicine is responsible for documenting the results of occupational fitness examinations accurately and objectively and recording them in the worker’s approved occupational health record, in accordance with the forms and procedures specified in this regulation, while adhering to the provisions of the Personal Data Protection and Health Privacy Law.

6- The records shall include all medical observations, entries, and recommendations, signed, dated and completed by the competent doctor, and kept in the worker’s file with the concerned authority, with a copy of them provided to the Secretariat of the National Council for Occupational Safety and Health when needed.

7- The entity keeping the medical records shall keep the occupational health record for a period of not less than ten (10) years from the date of the last examination, or for a period of five (5) years after the termination of the employment relationship, whichever is longer. In the event that the worker has been exposed during his period of employment to substances or agents with a long latency period or delayed health effects, such as asbestos or ionizing radiation, the register must be kept for a period of not less than thirty (30) years after the cessation of work and until the worker reaches the age of seventy-five, in accordance with NRRC-R-01 Rev. 0.1, 2024, section 166.C, and the approved international standards.

Article Eighteen

1- This regulation shall apply to all employees within the territory of the Kingdom of Saudi Arabia, including employees of government agencies, private sector establishments, or non-profit organizations, including workers in diplomatic and consular missions and official offices of the Kingdom abroad.

2- The provisions of these Regulations shall not apply to workers who practice their work outside the Kingdom for Saudi establishments, unless the employment contract expressly stipulates that they are subject to them.

3- If the employment contract includes a provision that the worker is subject to the provisions of these Regulations while practicing his work outside the Kingdom, this shall not conflict with the regulations in force in the country in which the worker practices his work.

4- The Saudi establishment shall, in the cases provided for in paragraph (3), verify the legality of the application of the provisions of the Regulations in the host State, and shall take all possible measures to adapt the implementation of medical examinations and occupational health measures to achieve the preventive purpose, without violating local laws or prejudice to the rights of the worker.

Article Nineteen

In the event of a violation of the provisions of this regulation, the penalties and sanctions stipulated in the relevant laws, regulations, and decisions within the supervisory scope of the competent authorities shall be applied.

Article Twenty

The Council shall issue the regulatory rules, provisions, and guidelines related to these Regulations. Article Twenty-One: The Council may issue guidelines, decisions, regulatory rules, and provisions related to the implementation of thes

المرفق 1: نموذج الفحوصات الطبية العامة يشمل جميع المهن بخلاف الفئة المهنية التي تتطلب نماذج خاصة وفحوصات إضافية (GENERRAL MEDICAL SHEET). SEE THE APPENDIX FOR CANDIDATE’S PERSONAL DECLARATION
Personal information
Job Code:			Job Title: Date of joining current job:
Name in full (last, first, middle):		National ID: Iqama No	Employment: New hire Rehire
Date of birth:	Gender: Male Female	Marital Status: Single Married (IF Yes) Pregnant (If applicable) Yes No
Address & telephone No.		Email address:
Health Questionnaire
Do you currently have or previously had any of the following conditions?
1- Cardiovascular problems (High blood pressure, palpitation, Heart/blood vessel disease or fainting) or others.				Yes No
2- Chest problems (asthma, difficulty breathing, chest tightness, coughing or others)				Yes No
3- Any neurological disorder e.g. (severe/frequent headaches, unsteadiness, stroke, transient ischemic attacks, tremors, sleep disorder, paralysis) or others				Yes No
4- Epilepsy, Convulsions or loss of consciousness				Yes No
5- Musculoskeletal problems (Joint problems, Restricted mobility, Back problems, Fractures/ dislocations)				Yes No
6- Psychological disorders e.g. (Anxiety, depression, psychosis, bipolar, Phobia)				Yes No
7- Any Eye/vision problem or color blindness				Yes No
8- Thyroid or other endocrine problem				Yes No
9- Diabetes				Yes No
10- Ear, nose, throat, hearing difficulties, tinnitus, or motion sickness requiring medication				Yes No
11- Blood disorders/ anemia (e.g. Sickle cell anemia) or others				Yes No
12- Urinary problem (Kidney, Bladder or Prostate)				Yes No
13- Skin problem (e.g. allergies or dermatitis)				Yes No
14- Infectious/contagious diseases				Yes No
15- Tuberculosis				Yes No
16- Digestive problem				Yes No
17- Sleeping Disorders (OSA or Day Time Sleepiness)				Yes No
18- Significant injuries				Yes No
19- Cancer				Yes No
20- Have you ever had any surgeries?				Yes No
21- Have you ever been hospitalized?				Yes No
22- Suicide attempt			Yes No
23- Autoimmune/connective tissue diseases (e.g. Rheumatoid arthritis)			Yes No
24- Any health problem, which requires visits to the doctor, or for which you take regular drugs for? If any of the above questions were answered “yes”, please give details by referencing the item number. Provide information regarding diagnosis and treatment, including dates of treatment.			Yes No
Occupational History:
25- Have you ever been exposed to fumes, dust, chemicals, loud noise, radiation, or other hazards at work or elsewhere? IF YES, Industry: ————— Job title: ————- Employer address: ———————- Dates of employment: ———————- Type of exposure………………… Duration of exposure……………. Refer to Occupational Exposure questionnaire				Yes No
26- Have you ever received worker’s disability benefits/ compensation?				Yes No
27- Have you been absent from work for medical reasons in the past five years?				Yes No
28- Have you ever required light or restricted duty? List type and duration				Yes No
29- Have you ever had any occupational illness				Yes No
If any of the above questions were answered “yes”, please give details by referencing item number.
Do you use :
Tobacco (Cigarettes, Shisha, pipe, Vape, …….)				Yes No
Alcohol				Yes No
Substance				Yes No
If yes, Current use Previous use Give details:
Were you subjected to medical examinations (within the past 6 months)				Yes No
If yes, please Specify:
– Type of assessment: —————————————————————————————
– Purpose: ——————————————————————————————————-
– Medical facility: ———————————————————————————————–
– Date of examination: —————————————————————————————-
– Attach results if applicable. :——————————————————————————-
Vaccination information:
If you are not fully vaccinated, are you willing to take the vaccine (s) for work purposes in KSA? Yes No
General:
Height (cm):	Weight (Kg):	BMI (consider waistto-hip ratio as best alternative)

Pulse rate: ____/min Regular Irregular Respiratory rate: ____/min Blood pressure (mm Hg): Systolic: ______ Diastolic: _______			Temperature
Vision: Visual Acuity
Unaided			Aided
Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20			Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20
(Tick the appropriate)
Visual field
Rt. Eye Normal	Defective
Lt. Eye Normal	Defective
Color vision: Normal Defective: Red green/others
Hearing:
Whisper test (6 feet):
RIGHT EAR PASS FAIL		LEFT EAR PASS FAIL
IF IMPAIRED, AUDIOMETRY SHOULD BE DONE
Physical Findings: (Circle the appropriate)
General Appearance			Normal Abnormal
1- Pallor			Normal Abnormal
2- Edema			Normal Abnormal
3- Jaundice			Normal Abnormal
4- Heart (Rhythm, sounds and murmurs)			Normal Abnormal
5- Cognitive functions			Normal Abnormal
6- Psychiatric (appearance, behavior, mood, thoughts, communication, and memory)			Normal Abnormal
7- Mouth/teeth			Normal Abnormal
8- Ears, nose, throat			Normal Abnormal
9- Lung and Chest (not including breast exam)			Normal Abnormal
10- Abdomen (including organomegaly and hernia)			Normal Abnormal
11- Urinary and genital system (not including pelvic exam)			Normal Abnormal
12- Upper & lower extremities (strength and range of motion)			Normal Abnormal
13- Spine			Normal Abnormal
14- Neurological (Equilibrium, tendon reflexes, coordination, etc.,)			Normal Abnormal
15- Skin			Normal Abnormal
Details of abnormality:—————————————————————————————————————————————————————————————————————- ——————————————————————————————————————————————————————————

Investigation

– Complete Urine Analysis

– )HbA1C )only if known diabetic or abnormal urinalysis

– Electrocardiogram (ECG) (above the age of 40 years only)

– Chest X-ray Post-Ant view (CXR-PA), (if clinically indicated).

– Audiometry (if clinically indicated or as baseline for applicable jobs) HEALTHCARE:

– Complete Blood Count (CBC)

– Urine Drug Screening

– Liver and renal function

– HBV, HCV, and HIV screening (If vaccinated against HBV, a HBsAb titer should be performed).

– If vaccinated or has previous natural infection with Measles, Mumps, Rubella or Varicella, a document of the presence of protective serum IgG against those infections is mandatory.

– Interferon-gamma release assay (IGRA)

– Respiratory FIT testing (if needed). Occupationally Exposed Radiation Workers

– Complete Blood Count (CBC) with differential (baseline)

– Liver and Renal Function Tests (LFTs, RFTs) (baseline)

– Respiratory fit testing (bassline) MINING AND UNDERGROUND:

– Chest X-ray Post-Ant view (CXR-PA), (baseline).

– Spirometry and respiratory fit testing (baseline)

– Audiometry (baseline)

– Respiratory FIT testing (if needed) ARMED PERSONNEL:

– Hepatic and Renal function tests

– CBC & Hemoglobin electrophoresis, G6PD (Air Forces pilot and crew only)

– HBV, HCV, and HIV screening

– Spirometry

– Chest x-ray (baseline)

– Audiometry (bassline)

– Drug Screening (Preplacement & Random) OIL AND GAS:

– CBC and Hemoglobin Electrophoresis

– Audiometry (baseline) Job code: ID TYPE: ( NATIONAL ID ) (PASSPORT) ID NUMBER: )Attach copy} Fitness determination:

– FIT

– FIT with considerations

– FIT with restrictions.

– UNFIT

Name of health professional: Signature : Date

– Spirometry and respiratory fit testing (baseline) COMMERCIAL DRIVER:

– Audiometry (Baseline) average hearing loss of 0.5,1.0&2.0 kHz in better ear < 40dBA

– Visual field assessment if clinically indicated FIRE FIGHTER

– Aerobic capacity (minimum MET level of 12)

– Harvard Step Test or Chester treadmill walk test or Bruce protocol or equivalent

– CBC with differential, RBC indices and morphology, and platelet count

– Renal function test

– Fasting blood glucose

– Liver function test

– Lipid profile

– HIV Ab

– Hepatitis C screening + confirmation only if positive baseline and following occupational exposure

– Hepatitis B base line (HBsAg) and vaccination with titers 1-2 months after completion of 3 dose series.

– Tetanus/diphtheria /pertussis (Tdap) vaccine once then Td booster every

10 years

– Document (MMR) or provide two doses according to immunization guidelines.

– Spirometry: annually to measure (FVC), (FEV1), and the absolute FEV1/FVC ratio AVIATION:

– Comply with the roles set by the General Authority of Civil Aviation (GACA) regarding civil aviation periodic medical assessments or the Unified Aeromedical Guidelines for G.C.C Armed Forces as applicable.

– Only authorized aviation medical examiners have the authority to issue medical certificates.

– Certificates may be issued, denied, or forwarded to the General Authority of Civil Aviation (GACA) for additional review via the website https://avmed.gaca. gov.sa/md ELECTRICAL LINE WORKERS:

– Visual assessment including color and depth perception testing

– Urine Drug Screening (pre-placement and random) Note: Copies of all investigation reports, X-ray reports, etc. … should be attached to this form as part of the record. Job title: Name of the candidate:

– All other fitness determinations should be referred to Occupational Medicine Specialist/Consultant, including:

المرفق 2: نموذج (MARINE MEDICAL SHEET) SEE THE APPENDIX FOR CANDIDATE’S PERSONAL DECLARATION
Personal information
Job Code:	Job Title: Date of joining current job:
Name in full (last, first, middle):	National ID: Iqama No	Employment: New hire Rehire
Department (deck/engine/radio/food handling/other): Routine and emergency duties (if known): Type of ship (e.g. container, tanker, passenger): Trade area (e.g. coastal, tropical, worldwide):	Date of birth: Gender: Male Female Marital Status: Single Married (IF Yes) Pregnant (If applicable) Yes No
Address & telephone No.	Email address:
Health Questionnaire
Do you currently have or previously had any of the following conditions?
1- Cardiovascular problems (High blood pressure, palpitation, Heart/blood vessel disease or fainting) or others.	Yes No
2- Chest problems (asthma, Difficulty breathing, chest tightness, coughing or others)	Yes No
3- Any neurological disorder e.g. (Severe/frequent headaches, Unsteadiness, Stroke, transient ischemic attacks, Tremors, sleep disorder, paralysis) or others	Yes No
4- Epilepsy, Convulsions or loss of consciousness	Yes No
5- Musculoskeletal problems (Joint problems, Restricted mobility, Back problems, Fractures/dislocations)	Yes No
6- Psychological disorders e.g. (Anxiety, depression, psychosis, bipolar, Phobia)	Yes No
7- Any Eye/vision problem or color blindness	Yes No
8- Thyroid or other endocrine problem	Yes No
9- Diabetes	Yes No
10- Ear, nose, throat, Hearing difficulties, tinnitus, or Motion sickness requiring medication	Yes No
11- Blood disorders/ anemia (e.g. Sickle cell anemia) or others	Yes No
12- Urinary problem (Kidney, Bladder or Prostate)	Yes No
13- Skin problem (e.g. allergies or dermatitis)	Yes No
14- Infectious/contagious diseases	Yes No
15- Tuberculosis	Yes No
16- Digestive problem	Yes No
17- Sleeping Disorders (OSA or Day Time Sleepiness)	Yes No
18- Significant injuries	Yes No
19- Cancer	Yes No
20- Have you ever had any surgeries?	Yes No
21- Have you ever been hospitalized?	Yes No
22- Suicide attempt	Yes No
23- Autoimmune/connective tissue diseases (e.g. Rheumatoid arthritis)	Yes No
24- Dizziness	Yes No
25- Varicose veins/piles	Yes No

26- Allergies to any medication, food, etc..?	Yes No
27- Hernia	Yes No
28- Amputation	Yes No
29- Have you ever been signed off as sick or repatriated from a ship?	Yes No
30- Have you ever been declared unfit for sea duty?	Yes No
31- Do you feel healthy and fit to perform the duties of your designated position/occupation?	Yes No
32- Any health problem, which requires visits to the doctor, or for which you take regular drugs? If any of the above questions were answered “yes”, please give details by referencing the item number. Provide information regarding diagnosis and treatment, including dates of treatment.	Yes No
Occupational history:
33- Have you ever been exposed to fumes, dust, chemicals, loud noise, radiation, or other hazards at work or elsewhere? IF YES, Industry: ————— Job title: ————- Employer address: ———————- Dates of employment: ———————- Type of exposure………………… Duration of exposure……………. Refer to Occupational Exposure questionnaire	Yes No
34- Have you ever received worker’s disability benefits/ compensation?	Yes No
35- Have you been absent from work for medical reasons in the past five years?	Yes No
36- Have you ever required light or restricted duty? List type and duration	Yes No
37- Have you ever had any occupational illness	Yes No
If any of the above questions were answered “yes”, please give details by referencing item number.
Do you use:
Tobacco (Cigarettes, Shisha, pipe, Vape, …….)	Yes No
Alcohol	Yes No
Substance	Yes No
If yes, Current use Previous use Give details:
Were you subjected to medical examinations (within the past 6 months)	Yes No
If yes, please Specify:
– Type of assessment: —————————————————————————————
– Purpose : ——————————————————————————————————-
– Medical facility : ———————————————————————————————–
– Date of examination: —————————————————————————————-
– Attach results if applicable. :——————————————————————————-
Vaccination information:
?If you are not fully vaccinated, are you willing to take the vaccine (s) for work purposes in KSA Yes No

PHYSICAL EXAMINATION
General:
Height (cm) :	Weight (Kg):	BMI (consider waistto-hip ratio as best alternative)
Pulse rate: ____/min Regular Irregular Respiratory rate: ____/min	Blood pressure (mm Hg): Systolic: _____ Diastolic: _______	Temperature
Vision: Visual Acuity
Unaided		Aided
Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20		Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20
(Tick the appropriate)
Visual field
Rt. Eye	Normal	Defective
Lt. Eye	Normal	Defective
Color vision: Normal Defective: Red-green/others
Hearing:
Whisper test (6 feet):
RIGHT EAR PASS FAIL		LEFT EAR PASS FAIL
IF IMPAIRED, AUDIOMETRY SHOULD BE DONE
Physical Findings: (Circle the appropriate)
General Appearance		Normal Abnormal
1- Pallor		Normal Abnormal
2- Edema		Normal Abnormal
3- Jaundice		Normal Abnormal
4- Heart (Rhythm, sounds and murmurs)		Normal Abnormal
5- Cognitive functions		Normal Abnormal
6- Psychiatric (appearance, behavior, mood, thoughts and communication, and memory)		Normal Abnormal
7- Mouth/teeth		Normal Abnormal
8- Ears, nose, throat Sinuses, tympanic membrane		Normal Abnormal
9- Eyes		Normal Abnormal
10- Ophthalmoscopy		Normal Abnormal
11- Pupils		Normal Abnormal
12- Eye movement		Normal Abnormal
13- Varicose veins		Normal Abnormal
14- Anus (Not including digital examination)		Normal Abnormal
15- Lung and Chest (not including breast exam)		Normal Abnormal
16- Abdomen (including organomegaly and hernia)		Normal Abnormal
17- Urinary and genital system (not including pelvic exam)		Normal Abnormal
18- Upper & lower extremities (strength and range of motion)		Normal Abnormal
19- Spine		Normal Abnormal
20- Neurological (Equilibrium, tendon reflexes, coordination, etc.,)		Normal Abnormal
21- Skin		Normal Abnormal
Details of abnormality:—————————————————————————————————————————————————————————————————————- ————————————————————————————————————————————————————

Investigation

– Urine Analysis

– HIV Ab and Hepatitis screening

– HbA1C (only if known diabetic or abnormal urinalysis)

– Electrocardiogram (ECG) (above age of 40 years only)

– Chest X-ray Post-Ant view (CXR-PA), (if clinically indicated).

– Audiometry (if clinically indicated or as baseline for applicable jobs)

FINAL DECISION OF PRE-PLACEMENT MEDICAL EXAMINATION REPORT
Assessment of fitness for service at sea On the basis of the examinee’s personal declaration, my clinical examination and the diagnostic test results recorded above, I declare the examinee medically:
Fit for look-out duty		Not fit for look-out duty
	Deck service	Engine service			Catering service		Other services
Fit
Unfit
Without restrictions	With restrictions	Visual aid required			Yes No
Job title: Name of the candidate: Job code: ID TYPE: ( NATIONAL ID ) (PASSPORT) ID NUMBER: (Attach copy} Medical opinion based on: – FIT – All other fitness determinations should be referred to Occupational Medicine Specialist/Consultant, including: – FIT with considerations – FIT with restrictions. – UNFIT Medical certificate’s date of expiration )day/month/year): Name of Heath Professional: Signature Date:
المرفق 3: نموذج (FOOD HANDLERS MEDICAL SHEET) SEE THE APPENDIX FOR CANDIDATE’S PERSONAL DECLARATION
Personal information
Job Title : Job Code : Date of joining current job:
Name in full (last, first, middle):			National ID : Iqama No			Employment: New hire Rehire
Date of birth :			Gender : Male Female			Marital Status: Single Married (IF Yes) Pregnant (If applicable) YES NO
Address & telephone No.			Email address :
Health Questionnaire
Do you currently have or previously had any of the following conditions?
1- Cardiovascular problems (High blood pressure, palpitation, Heart/blood vessel disease or fainting) or others.				Yes No
2- Chest problems (asthma, Difficulty breathing, chest tightness, coughing or others)				Yes No
3- Any neurological disorder e.g. (Severe/frequent headaches, Unsteadiness, Stroke, transient ischemic attacks, Tremors, sleep disorder, paralysis) or others				Yes No
4- Epilepsy, Convulsions or loss of consciousness				Yes No

PROFESSIONAL LICENSE OR CERTIFICATE If you are professionally licensed or certified to perform your current job (pilot, ship crew, respirator user, crane operator, firefighter, and others) please attach a copy of your professional license or certificate. Note: Copies of all investigation reports, X-ray reports, etc … should be attached to this form as part of the record.

5- Musculoskeletal problems (Joint problems, Restricted mobility, Back problems, Fractures/ dislocations)	Yes No
6- Psychological disorders e.g. (Anxiety, depression, psychosis, bipolar, Phobia)	Yes No
7- Any Eye/vision problem or color blindness	Yes No
8- Thyroid or other endocrine problem	Yes No
9- Diabetes	Yes No
10- Ear, nose, throat, Hearing difficulties, tinnitus, or Motion sickness requiring medication	Yes No
11- Blood disorders/ anemia (e.g. Sickle cell anemia) or others	Yes No
12- Urinary problem (Kidney, Bladder or Prostate)	Yes No
13- Skin problem (e.g. allergies or dermatitis)	Yes No
14- Infectious/contagious diseases	Yes No
15- Tuberculosis	Yes No
16- Digestive problem	Yes No
17- Sleeping Disorders (OSA or Day Time Sleepiness)	Yes No
18- Significant injuries	Yes No
19- Cancer	Yes No
20- Have you ever had any surgeries?	Yes No
21- Have you ever been hospitalized?	Yes No
22- Suicide attempt	Yes No
23- Autoimmune/connective tissue diseases (e.g. Rheumatoid arthritis)	Yes No
24- Liver disease
25- Deformity
26- Jaundice
27- Are you currently, or have you over the last seven days, suffered from diarrhea/vomiting?	Yes No
28- At present, are you suffering from : i. Skin trouble affecting hands, arms or face ii. Boils, styes or sepsis on your fingers or hands iii. Discharge from eye, ear or gums/mouth	Yes No
29- Do you suffer from : i. Recurring skin or ear infection ? ii. A recurring bowel disorder	Yes No
30- In the last 5 days, have you been in contact with anyone who may have been suffering from cholera?	Yes No
31- In the last 7 days, have you been in contact with anyone with diarrhoea or vomiting?	Yes No
32- In the last 21 days have you been in contact with anyone who may have been suffering from typhoid or paratyphoid or jaundice person?	Yes No
33- Have you ever had, or are you now known to be a carrier of typhoid or paratyphoid? Or do not have a certificate of antityphoid vaccine (valid for 3 years)	Yes No
34- Have you ever had, or are you now known to have typhoid fever?	Yes No

35- Any health problem, which requires visits to the doctor, or for which you take regular drugs? If any of the above questions were answered “yes”, please give details by referencing the item number. Provide information regarding diagnosis and treatment, including dates of treatment.		Yes No
Occupational history:
36- Have you ever been exposed to fumes, dust, chemicals, loud noise, radiation, or other hazards at work or elsewhere? IF YES, Industry: ————— Job title: ————- Employer address: ———————- Dates of employment: ———————- Type of exposure………………… Duration of exposure……………. Refer to Occupational Exposure questionnaire		Yes No
37- Have you ever received worker’s disability/ compensation?		Yes No
38- Have you been absent from work for medical reasons in the past five years?		Yes No
39- Have you ever required light or restricted duty? List type and duration		Yes No
40- Have you ever had any occupational illness		Yes No
If any of the above questions were answered “yes”, please give details by referencing item number.
Do you use :
Tobacco (Cigarettes, Shisha, pipe, Vape, …….)		Yes No
Alcohol		Yes No
Substance		Yes No
If yes, Current use Previous use Give details:
Were you subjected to medical examinations (within the past 6 months)		Yes No
2. If yes, please Specify :
– Type of assessment: —————————————————————————————
– Purpose: ——————————————————————————————————-
– Medical facility: ———————————————————————————————–
– Date of examination: —————————————————————————————-
– Attach results if applicable. :——————————————————————————-
Vaccination information:
If you are not fully vaccinated, are you willing to take the vaccine (s) for work purposes in KSA? Yes No
PHYSICAL EXAMINATION
General:
Height (cm):	Weight (Kg):		BMI (consider waistto-hip ratio as best alternative)
Pulse rate: ____/min Regular Irregular Respiratory rate: ____/min	Blood pressure (mm Hg): Systolic: ______ Diastolic: _______		Temperature
Vision: Visual Acuity
Unaided	Aided

Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20	Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20
(Tick the appropriate)
Visual field
Rt. Eye	Normal			Defective
Lt. Eye	Normal			Defective
Color vision: Normal Defective: Red-green/others
Hearing:
Whisper test (6 feet):
RIGHT EAR PASS FAIL		LEFT EAR PASS FAIL
IF IMPAIRED, AUDIOMETRY SHOULD BE DONE
Physical Findings: (Circle the appropriate)
General Appearance			Normal Abnormal
1- Pallor			Normal Abnormal
2- Edema			Normal Abnormal
3- Jaundice			Normal Abnormal
4- Eye			Normal Abnormal
5- Conjunctiva			Normal Abnormal
6- Clubbing			Normal Abnormal
7- Cyanosis			Normal Abnormal
8- Cervical lymph node enlargement			Normal Abnormal
9- Nails conditions			Normal Abnormal
10- Heart (Rhythm, sounds and murmurs)			Normal Abnormal
11- Cognitive functions			Normal Abnormal
12- Psychiatric (appearance, behavior, mood, thoughts and communication, and memory, etc)			Normal Abnormal
13- Mouth/teeth			Normal Abnormal
14- Ears, nose, throat			Normal Abnormal
15- Lung and Chest (not including breast exam)			Normal Abnormal
16- Abdomen (including organomegaly and hernia)			Normal Abnormal
17- Urinary and genital system (not including pelvic exam)			Normal Abnormal
18- Upper & lower extremities (strength and range of motion)			Normal Abnormal
19- Spine			Normal Abnormal
20- Neurological (Equilibrium, tendon reflexes, coordination, etc,)			Normal Abnormal
21- Skin			Normal Abnormal
Details of abnormality:—————————————————————————————————————————————————————————————————————- ——————————————————————————————————————————————————————————

Investigation

– Complete Urine Analysis

– HbA1C (only if known diabetic or abnormal urinalysis)

– Electrocardiogram (ECG) (above the age of 40 years only)

– Chest X-ray Post-Ant view (CXR-PA) (if clinically indicated).

– Audiometry (if clinically indicated or as baseline for applicable jobs)

– QuantiFERON test

– Widal test

– Stool examination for ova & parasite

– Stool culture and sensitivity for S. typhi to R/O Typhoid carrier )if clinically

FINAL DECISION OF PRE-PLACEMENT MEDICAL EXAMINATION REPORT
Job title: Name of the candidate: Job code: ID TYPE: NATIONAL PASSPORT ID NUMBER: )Attach copy} Fitness determination: – FIT – All other fitness determinations should be referred to Occupational Medicine Specialist/Consultant, including: – FIT with considerations – FIT with restrictions. – UNFIT Name of health professional: Signature: Date:
المرفق 4: نموذج (DIVING MEDICAL SHEET) SEE THE APPENDIX FOR CANDIDATE’S PERSONAL DECLARATION
Personal information
Job Code:	Job Title: Date of joining current job:
Name in full (last, first, middle):	National ID: Iqama No	Employment: New hire Rehire
Date of birth:	Gender: Male Female	Marital Status: Single Married (IF Yes) Pregnant (If applicable) Yes No
Address & telephone No.	Email address:
Health Questionnaire
Do you currently have or previously had any of the following conditions?
1- Cardiovascular problems (High blood pressure, palpitation, Heart/blood vessel disease or fainting) or others.		Yes No
2- Chest problems (asthma, Difficulty breathing, chest tightness, coughing or others)		Yes No
3- Any neurological disorder e.g. (Severe/frequent headaches, Unsteadiness, Stroke, transient ischemic attacks, Tremors, sleep disorder, paralysis) or others		Yes No
4- Epilepsy, Convulsions or loss of consciousness		Yes No
5- Musculoskeletal problems (Joint problems, Restricted mobility, Back problems, Fractures/dislocations)		Yes No
6- Psychological disorders e.g. (Anxiety, depression, psychosis, bipolar, Phobia)		Yes No

indicated- History of typhoid fever)

– Stool or Rectal swab culture and Sensitivity for Typhidot, Viral study to R/O Cholera, Typhoid, Shigellosis or EHEC infection (if clinically indicated – active diarrhoea with or without fever or dysentery)

– Anti- Hepatitis A Virus IgM (if clinically indicated – Jaundice and fever) Note: Copies of all investigation reports, X-ray reports , etc … should be attached to this form as part of the record.

7- Any Eye/vision problem or color blindness	Yes No
8- Thyroid or other endocrine problem	Yes No
9- Diabetes	Yes No
10- Ear, nose, throat, sinuses, Hearing difficulties, tinnitus, or Motion sickness requiring medication	Yes No
11- Blood disorders/ anemia (e.g. Sickle cell anemia) or others	Yes No
12- Urinary problem (Kidney, Bladder or Prostate)	Yes No
13- Skin problem (e.g. allergies or dermatitis)	Yes No
14- Infectious/contagious diseases	Yes No
15- Tuberculosis	Yes No
16- Digestive problem	Yes No
17- Sleeping Disorders (OSA or Day Time Sleepiness)	Yes No
18- Significant injuries	Yes No
19- Cancer	Yes No
20- Have you ever had any surgeries?	Yes No
21- Have you ever been hospitalized?	Yes No
22- Suicide attempt	Yes No
23- Autoimmune/connective tissue diseases (e.g. Rheumatoid arthritis)	Yes No
24- Have you ever had any diving related condition, eg barotrauma, decompression illness, immersion pulmonary oedema?	Yes No
25- Do you have any allergies?	Yes No
26- Do you have a family history of sudden cardiac death and/or abnormalities of heart rhythm?	Yes No
27- COVID-19	Yes No
28- Collapsed lung (pneumothorax)	Yes No
29- Dizziness	Yes No
30- Migraine	Yes No
31- Head injury with loss of consciousness, or surgery to the skull or brain	Yes No
32- Mental health problems (including panic attacks and claustrophobia)	Yes No
33- Stomach or intestinal problems or surgery (including stomas)	Yes No
1- Any health problem, which requires visits to the doctor, or for which you take regular drugs? If any of the above questions were answered “yes”, please give details by referencing the item number. Provide information regarding diagnosis and treatment, including dates of treatment.	Yes No
Occupational history:
2- Have you ever been exposed to fumes, dust, chemicals, loud noise, radiation, or other hazards at work or elsewhere? IF YES, Industry: ————— Job title: ————- Employer address: ———————- Dates of employment: ———————- Type of exposure………………… Duration of exposure……………. 3- Refer to Occupational Exposure questionnaire	Yes No
4- Have you ever received worker’s disability/ compensation?	Yes No
5- Have you been absent from work for medical reasons in the past five years?	Yes No
6- Have you ever required light or restricted duty? 7- List type and duration	Yes No
8- Have you ever had any occupational illness	Yes No
If any of the above questions were answered “yes”, please give details by referencing item number.
Do you use :
Tobacco (Cigarettes, Shisha, pipe, Vape, …….)	Yes No
Alcohol	Yes No
Substance	Yes No
If yes, Current use Previous use Give details:
Were you subjected to medical examinations (within the past 6 months)	Yes No
2- If yes, please Specify :
Type of assessment: —————————————————————————————
Purpose : ——————————————————————————————————-
Medical facility : ———————————————————————————————–
Date of examination : —————————————————————————————-
Attach results if applicable. :——————————————————————————-
Vaccination information :
If you are not fully vaccinated, are you willing to take the vaccine (s) for work purposes in KSA?	Yes No
PHYSICAL EXAMINATION

General:
Height (cm):	Weight (Kg):	BMI (consider hip: waistto-hip ratio as best alternative)
Pulse rate: ____/min Regular Irregular Respiratory rate: ____/min	Blood pressure (mm Hg): Systolic: ______ Diastolic: _______	Temperature
Vision : Visual Acuity
Unaided	Aided
Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20	Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20
(Tick the appropriate)
Visual field
Rt. Eye	Normal	Defective
Lt. Eye	Normal	Defective
Color vision: Normal Defective: Red-green/others
Hearing :
Whisper test (6 feet) :
RIGHT EAR PASS FAIL	LEFT EAR PASS FAIL
IF IMPAIRED, AUDIOMETRY SHOULD BE DONE
Physical Findings: (Circle the appropriate)
General Appearance		Yes No
1- Pallor		Yes No
2- Edema		Yes No
3- Jaundice		Yes No
4- Heart (Rhythm, sounds and murmurs)		Yes No
5- Cognitive functions		Yes No
6- Psychiatric (appearance, behavior, mood, thoughts and communication, and memory)		Yes No
7- Mouth/teeth		Yes No
8- Ears, nose, throat		Yes No

Job title: Name of the candidate: Job code: )Attach copy} Fitness determination:

– FIT

– FIT with considerations

– FIT with restrictions.

– UNFIT Name of health professional: Signature: Date:

– All other fitness determinations should be referred to Occupational Medicine Specialist/Consultant, including:

9- Lung and Chest (not including breast exam)	Yes No
10- Abdomen (including organomegaly and hernia)	Yes No
11- Urinary and genital system (not including pelvic exam)	Yes No
12- Upper & lower extremities (strength and range of motion)	Yes No
13- Spine	Yes No
14- Neurological (Equilibrium, tendon reflexes, coordination, etc,)	Yes No
15- Skin	Yes No
16- Posture	Yes No
17- Gait	Yes No
18- Balance	Yes No
19- Involuntary movements	Yes No
20- Speech	Yes No
21- Varicose vein	Yes No
22- Cranial nerve ll-Xll	Yes No
Details of abnormality:—————————————————————————————————————————————————————————————————————- ——————————————————
Investigation – BIOLOGICAL markers (for candidate with previous exposure to establish basle line/select applicable only) – Complete Urine Analysis – Lead, Pb (μg/L) – HbA1C (only if known diabetic or abnormal urinalysis) – Manganese, Mn (μg/L) – Electrocardiogram (ECG) (above the age of 40 years only) Cadmium, Cd (μg/L) – Chest X-ray Post-Ant view (CXR-PA), (if clinically indicated). – Audiometry (if clinically indicated or as baseline for applicable jobs) Note: – Spirometry Copies of all investigation reports, X-ray reports, etc. … should be attached to – Complete blood count this form as part of the record.
FINAL DECISION OF PRE-PLACEMENT MEDICAL EXAMINATION REPORT

المرفق 5: نموذج (WELDER MEDICAL SHEET) SEE THE APPENDIX FOR CANDIDATE’S PERSONAL DECLARATION
Personal information
Job Code:		Job Title: Date of joining current job:
Name in full (last, first, middle):	National ID: Iqama No	Employment: New hire Rehire
Date of birth:	Gender: Male Female	Marital Status: Single Married (IF Yes) Pregnant (If applicable) Yes No
Address & telephone No.	Email address :
Health Questionnaire
Do you currently have or previously had any of the following conditions?
1- Cardiovascular problems (High blood pressure, palpitation, Heart/blood vessel disease or fainting) or others.		Yes No
2- Chest problems (asthma, Difficulty breathing, chest tightness, coughing or others)		Yes No
3- Any neurological disorder e.g. (Severe/frequent headaches, Unsteadiness, Stroke, transient ischemic attacks, Tremors, sleep disorder, paralysis) or others		Yes No
4- Epilepsy, Convulsions or loss of consciousness		Yes No
5- Musculoskeletal problems (Joint problems, Restricted mobility, Back problems, Fractures/dislocations)		Yes No
6- Psychological disorders e.g. (Anxiety, depression, psychosis, bipolar, Phobia)		Yes No
7- Any Eye/vision problem or color blindness		Yes No
8- Thyroid or other endocrine problem		Yes No
9- Diabetes		Yes No
10- Ear, nose, throat, Hearing difficulties, tinnitus, or Motion sickness requiring medication		Yes No
11- Blood disorders/ anemia (e.g. Sickle cell anemia) or others		Yes No
12- Urinary problem (Kidney, Bladder or Prostate)		Yes No
13- Skin problem (e.g. allergies or dermatitis)		Yes No
14- Infectious/contagious diseases		Yes No
15- Tuberculosis		Yes No
16- Digestive problem		Yes No
17- Sleeping Disorders (OSA or Day Time Sleepiness)		Yes No
18- Significant injuries		Yes No
19- Cancer		Yes No
20- Have you ever had any surgeries?		Yes No
21- Have you ever been hospitalized?
22- Suicide attempt		Yes No

23- Autoimmune/connective tissue diseases (e.g. Rheumatoid arthritis)	Yes No
24- Allergic reactions that interfere with your breathing	Yes No
25- Claustrophobia	Yes No
26- Smelling	Yes No
27- Pulmonary symptoms (cough, wheezing, etc)	Yes No
28- Eye irritation	Yes No
29- Any health problem, which requires visits to the doctor, or for which you take regular drugs? If any of the above questions were answered “yes”, please give details by referencing the item number. Provide information regarding diagnosis and treatment, including dates of treatment.	Yes No
Occupational history:
30- Have you ever been exposed to fumes, dust, chemicals, loud noise, radiation, or other hazards at work or elsewhere? IF YES, Industry: ————— Job title: ————- Employer address: ———————- Dates of employment: ———————- Type of exposure………………… Duration of exposure……………. Refer to Occupational Exposure questionnaire	Yes No
31- Have you ever received worker’s disability/ compensation?	Yes No
Have you ever worked with any of the materials, or under any of the conditions listed below?
32- Asbestos?	Yes No
33- Silica (e.g., in sandblasting)?	Yes No
34- Tungsten/cobalt (e.g., grinding or welding this material)?	Yes No
35- Beryllium?	Yes No
36- Aluminum?	Yes No
37- Coal (for example, mining)?	Yes No
38- Iron?	Yes No
39- Tin?	Yes No
40- Dusty environments?	Yes No
41- Any other hazardous exposures?	Yes No
42- Have you been absent from work for medical reasons in the past five years?	Yes No
43- Have you ever required light or restricted duty? List type and duration	Yes No
44- Have you ever had any occupational illness	Yes No
If any of the above questions were answered “yes”, please give details by referencing item number.

Do you use:
Tobacco (Cigarettes, Shisha, pipe, Vape, …….)				Yes No
Alcohol				Yes No
Substance				Yes No
If yes, Current use Previous use Give details:
Were you subjected to medical examinations (within the past 6 months )				Yes No
2- If yes, please Specify:
– Type of assessment: —————————————————————————————
– Purpose: ——————————————————————————————————-
– Medical facility: ———————————————————————————————–
– Date of examination: —————————————————————————————-
– Attach results if applicable. :——————————————————————————-
Vaccination information:
If you are not fully vaccinated, are you willing to take the vaccine (s) for work purposes in KSA? Yes No
PHYSICAL EXAMINATION
General:
Height (cm):		Weight (Kg):		BMI (consider hip: waistto-hip ratio as best alternative)
Pulse rate: ____/min Regular Irregular Respiratory rate: ____/min		Blood pressure (mm Hg): Systolic: ______ Diastolic: _______		Temperature
Vision: Visual Acuity
Unaided				Aided
Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20				Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20
(Tick the appropriate)
Visual field
Rt. Eye	Normal			Defective
Lt. Eye	Normal			Defective
Color vision: Normal Defective: Red-green/others
Hearing:
Whisper test (6 feet):
RIGHT EAR PASS FAIL			LEFT EAR PASS FAIL
IF IMPAIRED, AUDIOMETRY SHOULD BE DONE
Physical Findings: (Circle the appropriate)

Job title: Name of the candidate: Job code: )Attach copy} Fitness determination:

– FIT

– FIT with considerations

– FIT with restrictions.

– UNFIT Name of health professional: Signature: Date:

– All other fitness determinations should be referred to Occupational Medicine Specialist/Consultant, including:

General Appearance	Normal Abnormal
1- Pallor	Normal Abnormal
2- Edema	Normal Abnormal
3- Jaundice	Normal Abnormal
4- Heart (Rhythm, sounds and murmurs)	Normal Abnormal
5- Cognitive functions	Normal Abnormal
6- Psychiatric (appearance, behavior, mood, thoughts and communication, and memory)	Normal Abnormal
7- Mouth (Tongue and tonsils), teeth and gums	Normal Abnormal
8- Ears, nose, throat	Normal Abnormal
9- Thyroid exam	Normal Abnormal
10- Lymph node	Normal Abnormal
11- Eye exam	Normal Abnormal
12- Lung and Chest (not including breast exam)	Normal Abnormal
13- Abdomen (including organomegaly and hernia)	Normal Abnormal
14- Urinary and genital system (not including pelvic exam)	Normal Abnormal
15- Upper & lower extremities (strength and range of motion)	Normal Abnormal
16- Spine	Normal Abnormal
17- Neurological (Equilibrium, tendon reflexes, coordination, etc,)	Normal Abnormal
18- Skin	Normal Abnormal
Details of abnormality:——————————————————————————————————————————————————————————————– ————————————————————————————————————————————————————————————————–
Investigation – BIOLOGICAL markers (for candidate with previous exposure to establish basle line/select applicable only) – Complete Urine Analysis – Lead, Pb (μg/L) – HbA1C (only if known diabetic or abnormal urinalysis) – Manganese, Mn (μg/L) – Electrocardiogram (ECG) (above the age of 40 years only) – Cadmium, Cd (μg/L) – Chest X-ray Post-Ant view (CXR-PA), (if clinically indicated). – Audiometry (if clinically indicated or as baseline for applicable jobs) Note: – Spirometry Copies of all investigation reports, X-ray reports, etc. … should be attached – Complete blood count to this form as part of the record.
FINAL DECISION OF PRE-PLACEMENT MEDICAL EXAMINATION REPORT

المرفق 6: نموذج (PERIODIC MEDICAL ASSESSMENTS) SEE THE APPENDIX FOR CANDIDATE’S PERSONAL DECLARATION
Personal information
Job Code:		Job Title: Date of joining current job :
Name in full (last, first, middle):	National ID: Iqama No	Employment: New hire Rehire
Date of birth:	Gender: Male Female	Marital Status: Single Married (IF Yes) Pregnant (If applicable) Yes No
Address & telephone No.	Email address :
Health Questionnaire
Do you currently have or previously had any of the following conditions?
1- Cardiovascular problems (High blood pressure, palpitation, Heart/blood vessel disease or fainting) or others.		Yes No
2- Chest problems (asthma, Difficulty breathing, chest tightness, coughing or others)		Yes No
3- Any neurological disorder e.g. (Severe/frequent headaches, Unsteadiness, Stroke, transient ischemic attacks, Tremors, sleep disorder, paralysis) or others		Yes No
4- Epilepsy, Convulsions or loss of consciousness		Yes No
5- Musculoskeletal problems (Joint problems, Restricted mobility, Back problems, Fractures/dislocations)		Yes No
6- Psychological disorders e.g. (Anxiety, depression, psychosis, bipolar, Phobia)		Yes No
7- Any Eye/vision problem or color blindness		Yes No
8- Thyroid or other endocrine problem		Yes No
9- Diabetes		Yes No
10- Ear, nose, throat, Hearing difficulties, tinnitus, or Motion sickness requiring medication		Yes No
11- Blood disorders/ anemia (e.g. Sickle cell anemia) or others		Yes No
12- Urinary problem (Kidney, Bladder or Prostate)		Yes No
13- Skin problem (e.g. allergies or dermatitis)		Yes No
14- Infectious/contagious diseases		Yes No
15- Tuberculosis		Yes No
16- Digestive problem		Yes No
17- Sleeping Disorders (OSA or Day Time Sleepiness)		Yes No
18- Significant injuries		Yes No
19- Cancer		Yes No
20- Have you ever had any surgeries?		Yes No
21- Have you ever been hospitalized?		Yes No
22- Suicide attempt		Yes No
23- Autoimmune/connective tissue diseases (e.g. Rheumatoid arthritis)		Yes No
24- Any health problem, which requires visits to the doctor, or for which you take regular drugs? If any of the above questions were answered “yes”, please give details by referencing the item number. Provide information regarding diagnosis and treatment, including dates of treatment.		Yes No
Occupational history:
25- Have you ever been exposed to fumes, dust, chemicals, loud noise, radiation, or other hazards at work or elsewhere? IF YES, Industry: ————— Job title: ————- Employer address: ———————- Dates of employment: ———————- Type of exposure………………… Duration of exposure……………. Refer to Occupational Exposure questionnaire		Yes No
26- Have you ever received worker’s disability/ compensation?		Yes No
27- Have you been absent from work for medical reasons in the past five years?		Yes No
28- Have you ever required light or restricted duty? List type and duration		Yes No
29- Have you ever had any occupational illness		Yes No
If any of the above questions were answered “yes”, please give details by referencing item number.
Do you use:
Tobacco (Cigarettes, Shisha, pipe, Vape, …….)	Yes No
Alcohol	Yes No
Substance	Yes No
If yes Current use Previous use :Give details,
Were you subjected to medical examinations (within the past 6 months)		Yes No
2- If yes, please Specify:
– Type of assessment: —————————————————————————————
– Purpose : ——————————————————————————————————-
– Medical facility : ———————————————————————————————–
– Date of examination : —————————————————————————————-
– Attach results if applicable. :——————————————————————————-
Vaccination information:
If you are not fully vaccinated, are you willing to take the vaccine (s) for work purposes in KSA? Yes No
PHYSICAL EXAMINATION

General:
Height (cm):	Weight (Kg): BMI (consider hip: waistto-hip ratio as best alternative)
Pulse rate: ____/min Regular Irregular Respiratory rate: ____/min	Blood pressure (mm Hg): Systolic: ______ Diastolic: _______		Temperature
Vision: Visual Acuity
Unaided Aided
Rt. Eye Rt. Eye Distant: /20 Near: /20 Distant: /20 Near: /20 Lt. Eye Lt. Eye Distant: /20 Near: /20 Distant: /20 Near: /20
(Tick the appropriate)
Visual field
Rt. Eye	Normal Defective
Lt. Eye	Normal Defective
Hearing:
Whisper test (6 feet) :
RIGHT EAR PASS FAIL		LEFT EAR PASS FAIL
IF IMPAIRED, AUDIOMETRY SHOULD BE DONE
Physical Findings: (Circle the appropriate)
General Appearance			Normal Abnormal
1- Pallor			Normal Abnormal
2- Edema			Normal Abnormal
3- Jaundice			Normal Abnormal
4- Heart (Rhythm, sounds and murmurs)			Normal Abnormal
5- Cognitive functions			Normal Abnormal
6- Psychiatric (appearance, behavior, mood, thoughts and communication, and memory)			Normal Abnormal
7- Mouth/teeth			Normal Abnormal
8- Ears, nose, throat			Normal Abnormal
9- Lung and Chest (not including breast exam)			Normal Abnormal
10- Abdomen (including hernia)			Normal Abnormal
11- Urinary and genital system (not including pelvic exam)			Normal Abnormal
12- Upper & lower extremities (strength and range of motion)			Normal Abnormal

Job title: Name of the candidate: Job code: )Attach copy} Fitness determination:

– FIT

– FIT with considerations

– FIT with restrictions.

– UNFIT Name of health professional: Signature: Date:

– All other fitness determinations should be referred to Occupational Medicine Specialist/Consultant, including:

Physical Findings: (Circle the appropriate)
13- Spine			Normal		Abnormal
14- Neurological (Equilibrium, tendon reflexes, coordination, etc,)			Normal		Abnormal
15- Skin			Normal		Abnormal
Details of abnormality:—————————————————————————————————————————————————————————————————————- ——————————————————————————————————————————————————————————
Investigation AIRCRAFT (annual): – Urine Analysis – Follow GACA roles for periodic physical – Chest X-ray Post-Ant view (CXR-PA) (if clinically indicated) – Electrocardiogram (ECG) (above 40 years) FIRE FIGHTER (every two years) : – Audiometry (if whisper test is positive) – Aerobic capacity (minimum MET level of 12) HEAVY EQUIPMENT OPERATOR (every 3 years) -Harvard Step Test or Chester treadmill walk test or Bruce protocol or equiva- – Urine Drug Screening (Random) lent – CBC with differential, RBC indices and morphology, and platelet count HEALTHCARE (every two years for high risk jobs): – Renal function test – HBV, HCV, and HIV screening (If vaccinated against HBV, a HBsAb titer should – Fasting blood glucose be performed). – Liver function test – Interferon-gamma release assay (IGRA) (annual testing with baseline negative – Lipid profile test). – Respiratory FIT testing (if not already done). – HIV Ab – Urine Drug Screening (Random). – Hepatitis C screening + confirmation only if positive baseline and following occupational exposure Occupationally Exposed Radiation Workers (every three (3) years) – Hepatitis B base line (HBsAg) and vaccination with titers 1-2 months after – Complete Blood Count (CBC) with differential. completion of 3 dose series. – Tetanus/diphtheria /pertussis (Tdap) vaccine once then Td booster every 10 For over exposures, accidental exposure, pregnant or breast feeding radiation years workers (follow Exposure Guidelines). – Document (MMR) or provide two doses according to immunization guidelines. – Spirometry: annually to measure (FVC), (FEV1), and the absolute FEV1/FVC MINING UNDERGROUND (every three years): ratio – Chest X-ray Post-Ant view (CXR-PA), (baseline and every 3 years and annually – Urine Drug Screening after 10 years of exposure). – Spirometry and respiratory fit testing (baseline). PROFESSIONAL LICENSE OR CERTIFICATE – Audiometry (baseline). If you are professionally licensed or certified to perform your current job (pilot, – Urine Drug Screening (Random). ship crew, respirator user, crane operator, firefighter and others) please attach a – Respiratory FIT testing (if needed). copy of your professional license or certificate. COMMERCIAL DRIVER (every two years): – Audiometry (periodic) average hearing loss of 0.5,1.0&2.0 kHz in better ear < Note: 40dBA Copies of all investigation reports, X-ray reports , etc … should be attached to – Visual field assessment if clinically indicated this form as part of the record.
FINAL DECISION OF PRE-PLACEMENT MEDICAL EXAMINATION REPORT

المرفق 7: نموذج (-DIVING MEDICAL SHEET) ANNUAL SEE THE APPENDIX FOR CANDIDATE’S PERSONAL DECLARATION
Personal information
Job Code:		Job Title:
Name in full (last, first, middle):	National ID: Iqama No	Employmen t New hire Rehire:
Date of birth:	Gender: Male Female	Marital Status Single Married (IF Yes) Pregnant (If applicable) Yes No:
Address & telephone No.	Email address :
Health Questionnaire
Do you currently have or previously had any of the following conditions?
1- Cardiovascular problems (High blood pressure, palpitation, Heart/blood vessel disease or fainting) or others.		Yes No
2- Chest problems (asthma, Difficulty breathing, chest tightness, coughing or others)		Yes No
3- Any neurological disorder e.g. (Severe/frequent headaches, Unsteadiness, Stroke, transient ischemic attacks, Tremors, sleep disorder, paralysis) or others		Yes No
4- Epilepsy, Convulsions or loss of consciousness		Yes No
5- Musculoskeletal problems (Joint problems, Restricted mobility, Back problems, Fractures/dislocations)		Yes No
6- Psychological disorders e.g. (Anxiety, depression, psychosis, bipolar, Phobia)		Yes No
7- Any Eye/vision problem or color blindness		Yes No
8- Thyroid or other endocrine problem		Yes No
9- Diabetes		Yes No
10- Ear, nose, throat, sinuses, Hearing difficulties, tinnitus, or Motion sickness requiring medication		Yes No
11- Blood disorders/ anemia (e.g. Sickle cell anemia) or others		Yes No
12- Urinary problem (Kidney, Bladder or Prostate)		Yes No
13- Skin problem (e.g. allergies or dermatitis)		Yes No
14- Infectious/contagious diseases		Yes No
15- Tuberculosis		Yes No
16- Digestive problem		Yes No
17- Sleeping Disorders (OSA or Day Time Sleepiness)		Yes No
18- Significant injuries		Yes No
19- Cancer		Yes No
20- Have you ever had any surgeries?		Yes No
21- Have you ever been hospitalized?		Yes No

22- Suicide attempt	Yes No
23- Autoimmune/connective tissue diseases (e.g. Rheumatoid arthritis)	Yes No
24- Have you ever had any diving related condition, eg barotrauma, decompression illness, immersion pulmonary oedema?	Yes No
25- Do you have any allergies?	Yes No
26- Do you have a family history of sudden cardiac death and/or abnormalities of heart rhythm?	Yes No
27- COVID-19	Yes No
28- Collapsed lung (pneumothorax)	Yes No
29- Dizziness	Yes No
30- Migraine	Yes No
31- Head injury with loss of consciousness, or surgery to the skull or brain	Yes No
32- Mental health problems (including panic attacks and claustrophobia)	Yes No
33- Stomach or intestinal problems or surgery (including stomas)	Yes No
34- Any health problem, which requires visits to the doctor, or for which you take regular drugs? If any of the above questions were answered “yes”, please give details by referencing the item number. Provide information regarding diagnosis and treatment, including dates of treatment.	Yes No
Occupational history:
35- Have you ever been exposed to fumes, dust, chemicals, loud noise, radiation, or other hazards at work or elsewhere? IF YES, Industry: ————— Job title: ————- Employer address: ———————- Dates of employment: ———————- Type of exposure………………… Duration of exposure……………. Refer to Occupational Exposure questionnaire	Yes No
36- Have you ever received worker’s disability/ compensation?	Yes No
37- Have you been absent from work for medical reasons in the past five years?	Yes No
38- Have you ever required light or restricted duty? List type and duration	Yes No
39- Have you ever had any occupational illness	Yes No
If any of the above questions were answered “yes”, please give details by referencing item number.
Do you use :
Tobacco (Cigarettes, Shisha, pipe, Vape, …….)	Yes No
Alcohol	Yes No
Substance	Yes No
If yes, Current use Previous use Give details:
Were you subjected to medical examinations (within the past 6 months)	Yes No

2- If yes, please Specify:
– Type of assessment: —————————————————————————————
– Purpose: ——————————————————————————————————-
– Medical facility: ———————————————————————————————–
– Date of examination: —————————————————————————————-
– Attach results if applicable:——————————————————————————-
Vaccination information :
If you are not fully vaccinated, are you willing to take the vaccine (s) for work purposes in KSA? Yes No
PHYSICAL EXAMINATION
General:
Height (cm):	Weight (Kg):	BMI (consider waistto-hip ratio as best alternative)
Pulse rate: ____/min Regular Irregular Respiratory rate: ____/min	Blood pressure (mm Hg): Systolic: ______ Diastolic: _______	Temperature
Vision : Visual Acuity
Unaided		Aided
Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20		Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20
(Tick the appropriate)
Visual field
Rt. Eye	Normal	Defective
Lt. Eye	Normal	Defective
Color vision: Normal Defective: Red-green/others
Hearing :
Whisper test (6 feet) :
RIGHT EAR PASS FAIL		LEFT EAR PASS FAIL
IF IMPAIRED, AUDIOMETRY SHOULD BE DONE
Physical Findings: (Circle the appropriate)
General Appearance		Normal Abnormal
1- Pallor		Normal Abnormal
2- Edema		Normal Abnormal
3- Jaundice		Normal Abnormal
4- Heart (Rhythm, sounds and murmurs)		Normal Abnormal
5- Cognitive functions		Normal Abnormal

Job title: Name of the candidate: Job code: )Attach copy} Fitness determination:

– FIT

– FIT with considerations

– FIT with restrictions.

– UNFIT Name of health professional: Signature: Date:

– All other fitness determinations should be referred to Occupational Medicine Specialist/Consultant, including:

6- Psychiatric (appearance, behavior, mood, thoughts and communication, and memory)	Normal Abnormal
7- Mouth/teeth	Normal Abnormal
8- Ears, nose, throat	Normal Abnormal
9- Lung and Chest (not including breast exam)	Normal Abnormal
10- Abdomen (including organomegaly and hernia)	Normal Abnormal
11- Urinary and genital system (not including pelvic exam)	Normal Abnormal
12- Upper & lower extremities (strength and range of motion)	Normal Abnormal
13- Spine	Normal Abnormal
14- Neurological (Equilibrium, tendon reflexes, coordination, etc,)	Normal Abnormal
15- Skin	Normal Abnormal
16- Posture	Normal Abnormal
17- Gait	Normal Abnormal
18- Balance	Normal Abnormal
19- Involuntary movements	Normal Abnormal
20- Speech	Normal Abnormal
21- Varicose vein	Normal Abnormal
22- Cranial nerve ll-Xll	Normal Abnormal
Details of abnormality:—————————————————————————————————————————————————————————————————————- ——————————————————————————————————————————————————————————
Investigation – Audiometry – Complete Urine Analysis – Complete blood count (if clinically indicated) – HbA1C (only if known diabetic or abnormal urinalysis) PROFESSIONAL LICENSE OR CERTIFICATE – Electrocardiogram (ECG) (above the age of 40 years only) – Chest X-ray Post-Ant view (CXR-PA), (if clinically indicated). If you are professionally licensed or certified to perform your current job (pilot, – Audiometry (if clinically indicated) ship crew, respirator user, crane operator, firefighter and others) please attach a – Aerobic capacity (minimum MET level of 12) copy of your professional license or certificate. Harvard Step Test or Chester treadmill walk test or Bruce protocol or equivalent Note: – Exercise test – Spirometry Copies of all investigation reports, X-ray reports , etc … should be attached to – Post-exercise PEF or FEV1 this form as part of the record.
FINAL DECISION OF PRE-PLACEMENT MEDICAL EXAMINATION REPORT

المرفق 8: نموذج (MINING MEDICAL SHEET) EVERY 3 YEARS UNTIL AGE OF 50, THEN EVERY ONE YEAR. SEE THE APPENDIX FOR CANDIDATE’S PERSONAL DECLARATION
Personal information
Job Code:		Job Title:
Name in full (last, first, middle):	National ID: Iqama No	Employment: New hire Rehire
Date of birth:	Gender: Male Female	Marital Status: Single Married (IF Yes) Pregnant (If applicable) Yes No
Address & telephone No.	Email address :
Health Questionnaire
Do you currently have or previously had any of the following conditions?
1- Cardiovascular problems (High blood pressure, palpitation, Heart/blood vessel disease or fainting) or others.		Yes No
2- Chest problems (asthma, Difficulty breathing, chest tightness, coughing or others)		Yes No
3- Any neurological disorder e.g. (Severe/frequent headaches, Unsteadiness, Stroke, transient ischemic attacks, Tremors, sleep disorder, paralysis) or others		Yes No
4- Epilepsy, Convulsions or loss of consciousness		Yes No
5- Musculoskeletal problems (Joint problems, Restricted mobility, Back problems, Fractures/dislocations)		Yes No
6- Psychological disorders e.g. (Anxiety, depression, psychosis, bipolar, Phobia)		Yes No
7- Any Eye/vision problem or color blindness		Yes No
8- Thyroid or other endocrine problem		Yes No
9- Diabetes		Yes No
10- Ear, nose, throat, Hearing difficulties, tinnitus, or Motion sickness requiring medication		Yes No
11- Blood disorders/ anemia (e.g. Sickle cell anemia) or others		Yes No
12- Urinary problem (Kidney, Bladder or Prostate)		Yes No
13- Skin problem (e.g. allergies or dermatitis)		Yes No
14- Infectious/contagious diseases		Yes No
15- Tuberculosis		Yes No
16- Digestive problem		Yes No
17- Sleeping Disorders (OSA or Day Time Sleepiness)		Yes No
18- Significant injuries		Yes No
19- Cancer		Yes No
20- Have you ever had any surgeries?		Yes No
21- Have you ever been hospitalized?
22- Suicide attempt		Yes No
23- Autoimmune/connective tissue diseases (e.g. Rheumatoid arthritis)		Yes No
24- Allergic reactions that interfere with your breathing		Yes No
25- Claustrophobia		Yes No
26- Smelling		Yes No
27- Pulmonary symptoms (cough, wheezing, etc)		Yes No
28- Eye irritation		Yes No
29- Any health problem, which requires visits to the doctor, or for which you take regular drugs? If any of the above questions were answered “yes”, please give details by referencing the item number. Provide information regarding diagnosis and treatment, including dates of treatment.		Yes No
Occupational history:
30- Have you ever been exposed to fumes, dust, chemicals, loud noise, radiation, or other hazards at work or elsewhere? IF YES, Industry: ————— Job title: ————- Employer address: ———————- Dates of employment: ———————- Type of exposure………………… Duration of exposure……………. Refer to Occupational Exposure questionnaire		Yes No
31- Have you ever received worker’s disability/ compensation?		Yes No
Have you ever worked with any of the materials, or under any of the conditions listed below?
32- Asbestos?		Yes No
33- Silica (e.g., in sandblasting)?		Yes No
34- Tungsten/cobalt (e.g., grinding or welding this material)?		Yes No
35- Beryllium?		Yes No
36- Aluminum?		Yes No
37- Coal (for example, mining)?		Yes No
38- Iron?		Yes No
39- Tin?		Yes No
40- Dusty environments?		Yes No
41- Any other hazardous exposures?		Yes No
42- Have you been absent from work for medical reasons in the past five years?		Yes No
43- Have you ever required light or restricted duty? List type and duration		Yes No
44- Have you ever had any occupational illness		Yes No
If any of the above questions were answered “yes”, please give details by referencing item number.
Do you use :
Tobacco (Cigarettes, Shisha, pipe, Vape, …….)	Yes No
Alcohol	Yes No
Substance	Yes No

If yes, Current use Previous use Give details:
Were you subjected to medical examinations (within the past 6 months)			Yes No
2- If yes, please Specify :
– Type of assessment: —————————————————————————————
– Purpose : ——————————————————————————————————-
– Medical facility : ———————————————————————————————–
– Date of examination : —————————————————————————————-
– Attach results if applicable. :——————————————————————————-
Vaccination information :
If you are not fully vaccinated, are you willing to take the vaccine (s) for work purposes in KSA? Yes No
PHYSICAL EXAMINATION
General:
Height (cm):	Weight (Kg):		BMI (consider hip:waist ratio)
Pulse rate: ____/min Regular Irregular Respiratory rate: ____/min	Blood pressure (mm Hg): Systolic: ______ Diastolic: _______		Temperature
Vision : Visual Acuity
Unaided			Aided
Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20			Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20
(Tick the appropriate)
Visual field
Rt. Eye		Normal	Defective
Lt. Eye		Normal	Defective
Color vision: Normal Defective: Red-green/others
Hearing :
Whisper test (6 feet) :
RIGHT EAR PASS FAIL				LEFT EAR PASS FAIL
IF IMPAIRED, AUDIOMETRY SHOULD BE DONE
Physical Findings: (Circle the appropriate)

Job title: Name of the candidate: Job code: )Attach copy} Fitness determination:

– FIT

– FIT with considerations

– FIT with restrictions.

– UNFIT Name of health professional: Signature: Date:

– All other fitness determinations should be referred to Occupational Medicine Specialist/Consultant, including:

General Appearance	Normal Abnormal
1- Pallor	Normal Abnormal
2- Edema	Normal Abnormal
3- Jaundice	Normal Abnormal
4- Heart (Rhythm, sounds and murmurs)	Normal Abnormal
5- Cognitive functions	Normal Abnormal
6- Psychiatric (appearance, behavior, mood, thoughts and communication, and memory)	Normal Abnormal
70- Mouth (Tongue and tonsils), teeth and gums	Normal Abnormal
8- Ears, nose, throat	Normal Abnormal
9- Thyroid exam	Normal Abnormal
10- Lymph node	Normal Abnormal
11- Eye exam	Normal Abnormal
12- Lung and Chest (not including breast exam)	Normal Abnormal
13- Abdomen (including organomegaly and hernia)	Normal Abnormal
14- Urinary and genital system (not including pelvic exam)	Normal Abnormal
15- Upper & lower extremities (strength and range of motion)	Normal Abnormal
16- Spine	Normal Abnormal
17- Neurological (Equilibrium, tendon reflexes, coordination, etc,)	Normal Abnormal
18- Skin	Normal Abnormal
Details of abnormality:—————————————————————————————————————————————————————————————————————- ——————————————————————————————————————————————————————————
Investigation select applicable only( – Complete Urine Analysis Lead, Pb (μg/L) – HbA1C (only if known diabetic or abnormal urinalysis) Manganese, Mn (μg/L) – Electrocardiogram (ECG) (above the age of 40 years only) Cadmium, Cd (μg/L) – Chest X-ray Post-Ant view (CXR-PA), (if clinically indicated). Note: – Audiometry )if clinically indicated) – Spirometry Copies of all investigation reports, X-ray reports , etc … should be attached to – BIOLOGICAL markers )for exposed above the permissible exposure limits only/ this form as part of the record.
FINAL DECISION OF PRE-PLACEMENT MEDICAL EXAMINATION REPORT

المرفق 9: نموذج (WELDER MEDICAL SHEET) EVERY 3 YEARS UNTIL AGE OF 50, THEN EVERY ONE YEAR. SEE THE APPENDIX FOR CANDIDATE’S PERSONAL DECLARATION
Personal information
Job Code:		Job Title: Date of joining current job:
Name in full (last, first, middle):	National ID: Iqama No		Employment: New hire Rehire
Date of birth:	Gender: Male Female		Marital Status: Single Married (IF Yes) Pregnant (If applicable) Yes No
Address & telephone No.	Email address :
Health Questionnaire
Do you currently have or previously had any of the following conditions?
1- Cardiovascular problems (High blood pressure, palpitation, Heart/blood vessel disease or fainting) or others.			Yes No
2- Chest problems (asthma, Difficulty breathing, chest tightness, coughing or others)			Yes No
3- Any neurological disorder e.g. (Severe/frequent headaches, Unsteadiness, Stroke, transient ischemic attacks, Tremors, sleep disorder, paralysis) or others			Yes No
4- Epilepsy, Convulsions or loss of consciousness			Yes No
5- Musculoskeletal problems (Joint problems, Restricted mobility, Back problems, Fractures/dislocations)			Yes No
6- Psychological disorders e.g. (Anxiety, depression, psychosis, bipolar, Phobia)			Yes No
7- Any Eye/vision problem or color blindness			Yes No
8- Thyroid or other endocrine problem			Yes No
9- Diabetes			Yes No
10- Ear, nose, throat, Hearing difficulties, tinnitus, or Motion sickness requiring medication			Yes No
11- Blood disorders/ anemia (e.g. Sickle cell anemia) or others			Yes No
12- Urinary problem (Kidney, Bladder or Prostate)			Yes No
13- Skin problem (e.g. allergies or dermatitis)			Yes No
14- Infectious/contagious diseases			Yes No
15- Tuberculosis			Yes No
16- Digestive problem			Yes No
17- Sleeping Disorders (OSA or Day Time Sleepiness)			Yes No
18- Significant injuries			Yes No
19- Cancer			Yes No
20- Have you ever had any surgeries?			Yes No
21- Have you ever been hospitalized?
22- Suicide attempt			Yes No

23- Autoimmune/connective tissue diseases (e.g. Rheumatoid arthritis)	Yes No
24- Allergic reactions that interfere with your breathing	Yes No
25- Claustrophobia	Yes No
26 Smelling	Yes No
27- Pulmonary symptoms (cough, wheezing, etc)	Yes No
28- Eye irritation	Yes No
29- Any health problem, which requires visits to the doctor, or for which you take regular drugs? If any of the above questions were answered “yes”, please give details by referencing the item number. Provide information regarding diagnosis and treatment, including dates of treatment.	Yes No
Occupational history:
30- Have you ever been exposed to fumes, dust, chemicals, loud noise, radiation, or other hazards at work or elsewhere? IF YES, Industry: ————— Job title: ————- Employer address: ———————- Dates of employment: ———————- Type of exposure………………… Duration of exposure……………. Refer to Occupational Exposure questionnaire	Yes No
31- Have you ever received worker’s disability/ compensation?	Yes No
Have you ever worked with any of the materials, or under any of the conditions listed below?
32- Asbestos?	Yes No
33- Silica (e.g., in sandblasting)?	Yes No
34- Tungsten/cobalt (e.g., grinding or welding this material)?	Yes No
35- Beryllium?	Yes No
36- Aluminum?	Yes No
37- Coal (for example, mining)?	Yes No
38- Iron?	Yes No
39- Tin?	Yes No
40- Dusty environments?	Yes No
41- Any other hazardous exposures?	Yes No
42- Have you been absent from work for medical reasons in the past five years?	Yes No
43- Have you ever required light or restricted duty? List type and duration	Yes No
44- Have you ever had any occupational illness	Yes No
If any of the above questions were answered “yes”, please give details by referencing item number.
Do you use :
Tobacco (Cigarettes, Shisha, pipe, Vape, …….)	Yes No

Alcohol				Yes No
Substance				Yes No
If yes, Current use Previous use Give details:
Were you subjected to medical examinations (within the past 6 months )				Yes No
2- If yes, please Specify:
– Type of assessment: —————————————————————————————
– Purpose: ——————————————————————————————————-
– Medical facility: ———————————————————————————————–
– Date of examination: —————————————————————————————-
– Attach results if applicable. :——————————————————————————-
Vaccination information:
If you are not fully vaccinated, are you willing to take the vaccine (s) for work purposes in KSA? Yes No
PHYSICAL EXAMINATION
General:
Height (cm):		Weight (Kg):		BMI (consider hip: waistto-hip ratio as best alternative)
Pulse rate: ____/min Regular Irregular Respiratory rate: ____/min		Blood pressure (mm Hg): Systolic: ______ Diastolic: _______		Temperature
Vision : Visual Acuity
Unaided				Aided
Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20				Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20
(Tick the appropriate)
Visual field
Rt. Eye	Normal			Defective
Lt. Eye	Normal			Defective
Color vision: Normal Defective: Red-green/others
Hearing :
Whisper test (6 feet) :
RIGHT EAR PASS FAIL			LEFT EAR PASS FAIL
IF IMPAIRED, AUDIOMETRY SHOULD BE DONE
Physical Findings: (Circle the appropriate)

Job title: Name of the candidate: Job code: )Attach copy} Fitness determination:

– FIT

– FIT with considerations

– FIT with restrictions.

– UNFIT Name of health professional: Signature: Date:

– All other fitness determinations should be referred to Occupational Medicine Specialist/Consultant, including:

General Appearance	Normal Abnormal
1- Pallor	Normal Abnormal
2- Edema	Normal Abnormal
3- Jaundice	Normal Abnormal
4- Heart (Rhythm, sounds and murmurs)	Normal Abnormal
5- Cognitive functions	Normal Abnormal
6- Psychiatric (appearance, behavior, mood, thoughts and communication, and memory)	Normal Abnormal
7- Mouth (Tongue and tonsils), teeth and gums	Normal Abnormal
8- Ears, nose, throat	Normal Abnormal
9- Thyroid exam	Normal Abnormal
10- Lymph node	Normal Abnormal
11- Eye exam	Normal Abnormal
12- Lung and Chest (not including breast exam)	Normal Abnormal
13- Abdomen (including organomegaly and hernia)	Normal Abnormal
14- Urinary and genital system (not including pelvic exam)	Normal Abnormal
15- Upper & lower extremities (strength and range of motion)	Normal Abnormal
16- Spine	Normal Abnormal
17- Neurological (Equilibrium, tendon reflexes, coordination, etc,)	Normal Abnormal
18- Skin	Normal Abnormal
Details of abnormality:—————————————————————————————————————————————————————————————————————- ——————————————————————————————————————————————————————————
Investigation – BIOLOGICAL markers (for candidate with previous exposure to establish basle – Complete Urine Analysis line/select applicable only) – HbA1C (only if known diabetic or abnormal urinalysis) Lead, Pb (μg/L) – Electrocardiogram (ECG) (above the age of 40 years only) Manganese, Mn (μg/L) – Chest X-ray Post-Ant view (CXR-PA), (if clinically indicated). Cadmium, Cd (μg/L) – Audiometry (if clinically indicated or as baseline for applicable jobs) Note: – Spirometry Copies of all investigation reports, X-ray reports, etc. … should be attached to – Complete blood count this form as part of the record.
FINAL DECISION OF PRE-PLACEMENT MEDICAL EXAMINATION REPORT

ID TYPE: NATIONAL PASSPORT ID NUMBER:

المرفق 10: نموذج (MINING AND UNDERGROUND MEDICAL SHEET) SEE THE APPENDIX FOR CANDIDATE’S PERSONAL DECLARATION
Personal information
Job Code:		Job Title:
Name in full (last, first, middle):	National ID: Iqama No	Employment: New hire Rehire
Date of birth:	Gender: Male Female	Marital Status: Single Married (IF Yes) Pregnant (If applicable) Yes No
Address & telephone No.	Email address :
Health Questionnaire
Do you now have or had any of the following conditions?
1- Cardiovascular problems (High blood pressure, palpitation, Heart/blood vessel disease or fainting) or others.		Yes No
2- Chest problems (asthma, Difficulty breathing, chest tightness or others)		Yes No
3- Any neurological disorder e.g. (Severe/frequent headaches, Unsteadiness, Stroke, transient ischemic attacks, Tremors, sleep disorder, paralysis) or others		Yes No
4- Epilepsy, Convulsions or loss of consciousness		Yes No
5- Musculoskeletal problems (Joint problems, Restricted mobility, Back problems, Fractures/dislocations)		Yes No
6- Psychological disorders e.g. (Anxiety, depression, psychosis, bipolar, Phobia)		Yes No
7- Any Eye/vision problem or color blindness		Yes No
8- Thyroid or other endocrine problem		Yes No
9- Diabetes		Yes No
10- Ear, nose, throat, Hearing difficulties, tinnitus, or Motion sickness requiring medication		Yes No
11- Blood disorders/ anemia (e.g. Sickle cell anemia) or others		Yes No
12- Urinary problem (Kidney, Bladder or Prostate)		Yes No
13- Skin problem (e.g. allergies or dermatitis)		Yes No
14- Infectious/contagious diseases		Yes No
15- Tuberculosis		Yes No
16- Digestive problem		Yes No
17- Sleeping Disorders (OSA or Day Time Sleepiness)		Yes No

18- Significant injuries	Yes No
19- Cancer	Yes No
20- Have you ever had any surgeries?	Yes No
21- Have you ever been hospitalized?	Yes No
22- Suicide attempt	Yes No
23- Autoimmune/connective tissue diseases (e.g. Rheumatoid arthritis)	Yes No
24- Any health problem, which requires visits to the doctor, or for which you take regular drugs? If any of the above questions were answered “yes”, please give details by referencing the item number. Provide information regarding diagnosis and treatment, including dates of treatment.	Yes No
Occupational history:
25- Have you ever been exposed to fumes, dust, chemicals, loud noise, radiation, or other hazards at work or elsewhere? IF YES, Industry: ————— Job title: ————- Employer address: ———————- Dates of employment: ———————- Type of exposure………………… Duration of exposure……………. Refer to Occupational Exposure questionnaire	Yes No
26- Have you ever received worker’s disability/ compensation?	Yes No
27- Have you been absent from work for medical reasons in the past five years?	Yes No
28- Have you ever required light or restricted duty? List type and duration	Yes No
29- Have you ever had any occupational illness	Yes No
If any of the above questions were answered “yes”, please give details by referencing item number.
Do you use :
Tobacco (Cigarettes, Shisha, pipe, Vape, …….)	Yes No
Alcohol	Yes No
Substance	Yes No
If yes, Current use Previous use Give details:
Were you subjected to medical examinations (within the past 6 months)	Yes No
2- If yes, please Specify :
– Type of assessment: —————————————————————————————
– Purpose : ——————————————————————————————————-

– Medical facility : ———————————————————————————————–
– Date of examination : —————————————————————————————-
– Attach results if applicable. :——————————————————————————-
Vaccination information :
PHYSICAL EXAMINATION
General:
Height (cm):	Weight (Kg):		BMI )consider waist-to-hip ratio as best
Pulse rate: ____/min Regular Irregular Respiratory rate: ____/min	Blood pressure (mm Hg): Systolic: ______ Diastolic: _______		Temperature
Vision : Visual Acuity
Unaided			Aided
Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20			Rt. Eye Distant: /20 Near: /20 Lt. Eye Distant: /20 Near: /20
(Tick the appropriate)
Visual field
Rt. Eye	Normal		Defective
Lt. Eye	Normal		Defective
Color vision: Normal Defective: Red-green/others
Hearing :
Whisper test (6 feet) :
RIGHT EAR PASS FAIL		LEFT EAR PASS FAIL
IF IMPAIRED, AUDIOMETRY SHOULD BE DONE
Physical Findings:
General Appearance			Normal Abnormal
1- Pallor			Normal Abnormal
2- Edema			Normal Abnormal
3- Jaundice			Normal Abnormal
4- Heart (Rhythm, sounds and murmurs)			Normal Abnormal
5- Cognitive functions			Normal Abnormal
6- Psychiatric (appearance, behavior, mood, thoughts and communication, and memory)			Normal Abnormal
7- Mouth/teeth			Normal Abnormal

Job title: Name of the candidate: Job code: ID TYPE: NATIONAL PASSPORT ID NUMBER: )Attach copy} Medical opinion based on:

– FIT

– FIT with considerations

– Fit with restrictions.

– UNFIT Name of Heath Professional : Signature: Date: CANDIDATE’S PERSONAL DECLARATION my immediate employment termination by my employer without termination benefits. epidemiological studies purposes. Name of candidate………………………. Signature………………… Date ……………………….

– All other fitness determinations should be referred to Occupational Medicine Specialist/Consultant, including: I, the undersigned, hereby affirm that I have given true and complete information to the best of my knowledge regarding my medical history. I understand and accept that if, after having been employed, any false statement or misrepresentation, or omitted material information will constitute a valid reason for I, the undersigned, hereby authorize the release of the information I have provided herein, and the results of any required medical examination, including the opinions and evaluations of the examining physicians, to the examining healthcare institute and their employees and authorized agents. I, the undersigned, do voluntarily agree to release and hold my employer and their employees and authorized agents harmless from any claim, demand or cause of action for damages arising from the review and release of my medical information for the purpose of consideration for employment or aggrigate data analysis for

8- Ears, nose, throat	Normal Abnormal
9- Lung and Chest (not including breast exam)	Normal Abnormal
10- Abdomen (including hernia)	Normal Abnormal
11- Urinary and genital system (not including pelvic exam)	Normal Abnormal
12- Upper & lower extremities (strength and range of motion)	Normal Abnormal
13- Spine	Normal Abnormal
14- Neurological (Equilibrium, tendon reflexes, coordination, etc,)	Normal Abnormal
15- Skin	Normal Abnormal
Details of abnormality:—————————————————————————————————————————————————————————————————————- ——————————————————————————————————————————————————————————
Details of abnormality:————————————————————————————————————————————————————– ————————————————————————————————————————————————————————————— —————————————– Investigation – Chest X-ray Post-Ant view (CXR-PA). – Spirometry and respiratory fit testing – Audiometry Note: Copies of all investigation reports, X-ray reports , etc … should be attached to this form as part of the record.
FINAL DECISION OF END OF SERVICE MEDICAL EXAMINATION REPORT