YOUR NAME MUST BE WRITTEN ON EACH PAGE OF THIS PACKET. INCOMPLETE SUBMMISIONS WILL NOT BE REVIEWED.
IMPORTANT: You must receive medical clearance from Halliburton before you are authorized to begin your international assignment. You will not be deployed to the Assignment Location or be eligible for any assignment-related benefits, premiums or provisions until this clearanceis obtained and reported to HR.
Please follow the steps outlined below immediately to avoid unnecessary delays.
The attached forms must
be fully completed by both you and the examining physician/examiner, as applicable. All documentation must be written in English or be accompanied by an English translation. 1. PRE-DEPARTURE EXAMINATION FORM (COUNTRY SPECIFIC) Describes the required medical tests for your country of assignment. All required tests must be performed by the examining physician and the results
forwarded to Halliburtons Medical & Disability Department for review. 2. PHYSICAL EXAMINATION RECORD The examining physician must complete this three (3) page document complete with signature.
3. MEDICAL QUESTIONNAIRE Complete this three (3) page questionnaire prior to undergoing the physical examination. Make this available to the examining physician. Be sure to return completed questionnaire to the Medical & Disability Department with this packet. Your name MUST
be written on each page of the Physical Examination Record as well as Medical Questionnaire. 4. IMMUNIZATION REQUIREMENTS- Complete this form and acknowledge consent. The examining physician MUST 5. MALARIA CHEMOPROPHYLAXIS COMPLIANCE REQUIREMENTS- Please read, sign and return this form if included with your protocol. sign the form indicating you have had the required vaccinations or you will be required to provide a copy of your vaccination records to the Medical & Disability Department.
6. MEDICAL AUTHORIZATION RELEASE FORM Please read, sign and return this form.
7. MEDICAL PACKET COVER LETTER- The physician should complete and use this form as the fax/email cover sheet when forwarding the Protocol and results on your behalf.
The completed packet should be sent by fax to: +1-281-902-1481, or send scanned copies of the packet including the cover letter via email to: resource.fhouforeign@halliburton.com. This should come DIRECTLY from the physicians office.
The company reviews and makes the final determination regarding your medical clearance for international assignments. Notification of determination is provided to the Human Resources Department.
Contact your HR Representative for updates on your medical clearance.
Revised 06/09
Pre-Departure Examination Azerbaijan
All tests, along with a physical exam, indicated below MUST Incomplete examinations will not be accepted and may delay assignment. be performed.
Name: Date:
Employee/ID Number: Date of Birth:
Country Assignment: AZERBAIJAN
Position: Commuter Expat
Urinalysis: Normal Abnormal Blood Work*: Normal Abnormal Audio: Normal Abnormal Spirometry: Normal Abnormal EKG**: Normal Abnormal Chest X-Ray***: Normal Abnormal *CBC, Retic, Blood Chemistry+ **Only required when individual is over 55 years of age or otherwise indicated by exam ***PA/LA if indicated
Respirator Approval Approval to use any appropriate respirator, but not SCBA Approval to use any appropriate respirator, including SCBA No respirator approval until cleared by corporate Medical Director
Physical Examination No medical conditions that preclude remote assignment based upon work assignment information provided and scope of health testing criteria. I find this person unfit for duty in this remote location. Cannot be medically cleared at this time. Recommendations for further evaluation are listed below.
I have advised the employee to follow up with his/her personal physician for the following medical conditions:
Physicians Signature: Date:
Revised 04/10 Page 1 of 3
PHYSICAL EXAMINATION RECORD (To be filled out by examining physician)
PRE-DEPARTURE 2 YEAR PERIODIC EXAM DEPENDENTS
NAME (LAST, FIRST, MIDDLE)
EMPLOYEE/ID NUMBER DATE OF BIRTH (MM/DD/YYYY)
JOB TITLE
ASSIGNMENT LOCATION
AGE
SEX
VITALS VISION HT UNCORRECTED
CORRECTED PERRIPHERAL VISUAL FIELD R_________ L_________ WT TEMP Far Near Far Near DEPTH PERCEPTION B/P B 20/ B 20/ B 20/ B 20/ Pulse /Min R 20/ R 20/ R 20/ R 20/ COLOR VISION Resp /Min L 20/ L 20/ L 20/ L 20/ WNL ABN
URINALYSIS Protein Blood Glucose
PHYSICAL EXAMINATIONFOR ABNORMAL FINDINGS, BOX, MARK (L) OR (R) AND EXPLAIN BELOW
Please comment on any significant positive or pertinent negative findings. Include any opinions as to what, if any, limitations regarding the performance of the functions of his/her position that should be placed on the examinee or any reasonable modifications of the workplace that need to be made to accommodate the examinee. If this is predeployment, do NOT comment specifically on whether the examinee is medically qualified to be hired.
No further evaluation:
Needs further evaluation:
Additional Comments:
Has examinee been counseled regarding findings and recommendations? Yes No
Will this examinees rating change in the next six months? Yes No
PLEASE PRINT
Examining Physician Name:
License Number:
Address:
Telephone Number: Fax Number:
Physicians Signature: Date:
Revised 04/10 Page 3 of 3
MEDICAL DECLARATION FORM
*PHYSICIAN: Must complete and sign form for validation of fitness for duty*
Last Name
First Name Employee/ID Number
Job Title
Assignment Location
MEDICAL RATING
(Please circle)
P Provisional Review required:________________________
A Fit for all types of work
B Fit for Office work/light duties
C Unfit for duty
Will this individuals rating change in the next 6 months? If yes, provide details.
Conclusion: I CERTIFY THAT ________________________________________ IS:
(Please check)
1. FIT FOR WORKING IN REGIONS WITH LIMITED MEDICAL RESOURCES
2. NOT FIT FOR WORKING IN REGIONS WITH LIMITED MEDICAL RESOURCES
3. QUALIFIED WITH RESTRICTIONS ___________________________________
Employee Questionnaire Form Name (first middle last): Assignment Location: Employee Type (circle one): New Hire Transfer Rehire Employee ID: Company (circle one): HES PRL HAPL HWL Other: _________________________ Home Address: Age: Sex: M F City: State/Province: Zip/Postal Code: Date of Birth (mm/dd/yyyy): / / Country: HR Contact: Contact Email: Contact Phone Number:
In the past 12 months have you had any surgery, medical care by a doctor or any change in your health? This includes dental, vision, hearing, prescription changes, etc. Yes No If yes, please explain:________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Have you ever been demobilized for medical reasons? Yes No Condition: __________________________________ MEDICAL HISTORY: YES NO YES NO YES NO Cancer Stroke Mental Illness Diabetes (indicate type I or II) Epilepsy/Seizures Drug/Alcohol Abuse Hepatitis (liver disease) Kidney Disease High Blood Pressure Allergies Coughing up phlegm Pneumonia Asthma Frequent colds Severe sore throat Broken ribs Hay fever Shortness of breath Bronchitis Spitting up blood Chronic cough Sleep Apnea Wheezing Night Sweats Are you currently using a CPAP or any other breathing device? Type: Anemia (low blood) Blood Transfusion Leukemia Bruising (easier than normal) Bleeding gums Sickle Cell Disease Difficulty in stopping bleeding Other blood issues type: ____________________________________ Numbness in arms/hands/legs/feet Muscle weakness/paralysis Anxiety/Nervousness Head injury/unconsciousness Epilepsy/Seizures/Convulsions Frequent headaches Other psychological disorders Depression Frequent dizziness Stomach pain Stomach ulcer Chronic indigestion Change in bowel habits Vomiting/nausea Rupture of hernia Excessive gas/bloating Black stools Blood in stools Unexplained weight loss/gain Hernia surgery Prostate problems Kidney/bladder infections Blood in urine Pain with urination Difficulty starting urination Gallbladder surgery Hepatitis A B C Cirrhosis Yellow Jaundice Other liver problems Alcohol consumption Daily oz. Occasional oz. Beer Wine Liquor If you indicated yes above, please use space to explain & include dates:
Revised 05/10 Page 2 of 3
YES NO YES NO YES NO Heart attack/heart disease Heart/chest surgery Chest pains High blood pressure Irregular or rapid heartbeat Stroke Enlarged heart Abnormal EKG Heart murmur Swelling of ankles Deep vein thrombosis Varicose veins Arthritis/gout/rheumatism Back injury Back pain Back surgery Joint swelling Knee problems Neck pain/whiplash Skin cracking/bleeding Skin itching/peeling Skin discolorations Skin rashes Skin allergies Mole/growth on skin Psoriasis/eczema Seen a skin doctor? Hearing difficulties Ear surgery Ears ringing Ear drainage Dizziness Ear aches Wear glasses/contacts (explain) For reading? For distance? Abnormal night vision Blurred vision Cataracts Burning/tearing/redness of eye Eye allergies or infections Eye surgery Difficulty with depth perception Glaucoma Color blindness Allergy to certain foods Allergy to certain medications Other allergies Smoke Cigarettes Number a day Number of years Smoke Cigars/Pipe Number a day Number of years Ex-Smoker Number a day Number of years If you indicated yes above, please use space to explain & include dates:
HAVE YOU BEEN SUBJECT TO THE FOLLOWING? : YES NO YES NO YES NO Noise Exposure Chemical or lead Exposure Radiation Exposure Asbestos Exposure Other Exposures: ________________________________________ Severe blow to the head Eardrum puncture Skull fracture Flying or skydiving accident Explosion or blast Knocked out Driving/auto accident Other trauma: ___________________________________________ If you indicated yes above, please use space to explain & include dates:
CURRENT SYMPTOMS Within the past 24 hours have you: YES NO YES NO YES NO Experienced ringing in your ears Taken ANY medication Had a toothache Had a cold, fluid or sinus condition Been exposed to loud noise without hearing protection If you indicated yes above, please use space to explain & include dates:
FEMALES ONLY: Is there any possibility that you may be pregnant? Yes No Date of last menstrual cycle ______/______/______
Revised 05/10 Page 3 of 3
1. Have you developed any medical condition with your occupation? Yes No If yes, please provide details (i.e. hearing loss/skin condition/wheezing/backache/muscle strain/blood disease) ________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 2. Have you ever been denied employment based upon medical grounds? Yes No If yes, please explain _________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 3. Do you consider yourself to be healthy? Yes No If no, please explain _________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 4. What medications do you regularly take? ____________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 5. List any hospitalization, major illnesses, injuries, surgeries or other conditions (physical or psychological) that you have EVER had along with the date: ______________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Continued explanations to ANY _____________________________________________________________________________________ question(s) from above: _____________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
I certify that the foregoing statements are true to the best of my knowledge. I understand that leaving out or misrepresenting the facts called for in this questionnaire may be the cause for refusal of employment or termination from the company. I hereby authorize the company to investigate the facts claimed by me on this questionnaire.
I hereby grant permission to the examining medical personnel and/or physician to disclose any information herein and hereinafter furnished by me, to authorized company personnel for purposes related to my employment at Halliburton and Associated Companies and to legal entities requiring such information.
I understand that the pre-placement physical examination given to me is only intended to obtain information for employment purposes of Halliburton and Associated Companies. It is not a physical examination of the type given by a physician to assess the state of my health and it may not be relied upon by me for that purpose. I must look to my personal physician for such an assessment.
I understand that the medical surveillance test given to me is intended to identify specific instances of illness or health trends suggesting an adverse effect of workplace exposures.
I understand that the examining physician / medical staff and the Halliburton Medical and Disability Department will disclose, in writing, to me and appropriate Halliburton safety and health personnel any findings which, in the physicians opinion, indicate any adverse effect of occupational exposure or pre-existing physical condition which precludes exposure to specific toxic materials or physical hazards.
____________________________________________________________ _______________________ Signature Date (mm/dd/yyyy)
Revised 05/10
Immunization Requirements Azerbaijan
This form must be completely filled out. Submission or incomplete forms may delay assignment. Name: Date of Birth:
Employee/ID Number: Country Assignment: AZERBAIJAN
Blood Type:
Halliburton REQUIRES employees traveling/working on international assignments in the above named country to be current on the immunizations listed below.
I have had the chance to ask questions and they were answered to my satisfaction. I understand the benefits and risks of the vaccine(s) indicated above and I agree to receive these vaccine(s).
Assignees Signature: Date:
I attest that the above named person is current on all the required vaccinations indicated above and any additional necessary vaccinations for the county in with they will be working/traveling.
Physicians Signature: Date:
Revised 06/09
MEDICAL AUTHORIZATION RELEASE
I acknowledge that the use of and/or possession of prohibited drugs, including inhalants, and unauthorized alcoholic beverages is a violation of Company policy.
As a condition of employment and further as a condition of performing services for my employer in support of existing contracts, I consent to submit to a physical examination, medical screening, or medical questionnaire(s) as required by my employer.
I also give my consent for specimens to be collected from me to be submitted of drug and /or alcohol testing and additional medical testing as required.
I agree that my employment shall be conditional pending the subsequent results of any medical evaluation and substance testing.
Further, I herby consent to the release of any and all test results to my employer for its use or use by an authorized agent.
I release and agree to hold my employer and all their officers, directors, employees and agents harmless from any claim or liability which for any reasons the Company is alleged to be legally liable in conjunction with the physical evaluation, or the drug and/or alcohol testing.
Assignees Signature: Date:
Witness Signature: Date:
Witness Name: Relationship: (PLEASE PRINT)
Revised 04/10
Medical Protocol Packet Submission Cover Letter
Assignees Name Assignees Employee/ID Number Country Assignment
Physician Name Physician Address
Physician Phone Number Physician Fax Number
Number of Pages (including cover page)
Return to the Medical & Disability Department Fax: 1-281- 902-1481 Email: resource.fhouforeign@halliburton.com