STATUTORY MEDICAL EXAMINATION FORM

STATUTORY MEDICAL EXAMINATION FORM
This questionnaire will only be used for purpose of assessing fitness to work with Statutory Exposures according to Ministry of Manpower (MOM The questionnaire is secured and meets the US HIPAA (Health Insurance Portability & Accountability Act) requirements for Medical Data protection. A password protected copy of filled questionnaire will be emailed to you to print and bring down to clinic.
Name (according to NRIC/FIN/ID)*
NRIC/FIN (required by MOM)*
Type of Statutory Medical*

Baseline (first time doing this)Periodic (have done this test previously)ExitOther
Job Title
Designation*

StaffStudentOther
Staff / Student Number (NUS only)
Department, Institution
Date of Birth (required by MOM)*

DayMonthYear
Date
Email*
example@example.com
Handphone (required by MOM)*
Type of Statutory Exposure*

ArsenicMercuryCadmiumLeadBenzeneManganeseSilicaOrganophosphatesNoiseAsbestosBitumenVinyl Chloride MonomersTarTrichloroethyleneCreosotePerchloroethylene
Please describe how much is your exposure? (Amount used, solid/liquid/gas, frequency, control measures and PPE used)
Did you have any incidents resulting in accidental exposure in the lab/at work in the past 1-3 years?

NoYes. Please describe below:Please check box and describe:
Date of Start of Exposure*

DayMonthYear
Date
Date of End of Exposure*
What other lab hazards are you exposed to?

Biological infectious agents (eg viruses, bacteria, fungi)lonising RadiationLasersHazardous chemicals (eg corrosives, carcinogens, toxics)Human specimens such as blood, tissues, other body fluids

Do you have the following conditions?*

Rows	No	Yes	Elaborate
Eye or Visual problems
Ear conditions, deafness or ringing sounds in ear
Giddiness or loss of balance
Fainting or fits/epilepsy
Heart disease, high blood pressure or chest pain
Lung disease eg asthma, pneumothorax
Chronic disorder of blood cells
Liver disorders
Kidney disorders
Nerve or Brain disorders, muscle weakness
Diabetes
Allergies
Pregancy

Estimated number of hours per day - listening to music with ear piece
If exposed to noise, do you use ear plugs/ear muffs when working in noisy area?

YesNoSometimesOther
Do you smoke?

DailySocial SmokerEx SmokerNon Smoker
Previous Test Results (if any)
Date of most recent Chest Xray

MonthDayYear
Date
Declaration*

I declare that I have answered this form truthfully and to the best of my knowledge. I understand that my institution at its discretion can choose not to bear costs of any future illness or treatment should there be false or incomplete declaration of the above.I consent for the relevant information to be conveyed to my Supervisor or Department or MOM.I consent to the release of my medical details to the treating clinic/hospital/doctor(s) concerned in the event of an incident or where deemed necessary.
Student/Staff Name & Signature*

Clear
Date*

DayMonthYear
Date
TO BE FILLED BY DOCTOR ONLY
Blood Pressure (mmHg)
Pulse Rate (bpm)

Hearing Results

Normal hearingNon-Occupational Hearing LossSuspected Noise Induced DeafnessEarly Noise Induced DeafnessAdvanced Noise Induced DeafnessSensorineural Hearing LossConduction Hearing LossOther

Blood Lead (ug/dl)
Haemoglobin (g%)
Urine Manganese (ug/L)
Urine Arsenic (ug/L)
Chest Xray, Liver Function Tests, Skin Examination

SatisfactoryAbnormalOther
Blood Cadmium (ug/L)
Urine Beta 2 Microglobulin (ug/gm Creatinine)
Urine Mercury (ug/L)
Urine TTMA (mg/grCr)
Full Blood Count and Peripheral Blood Film

SatisfactoryAbnormalComment
Urine Trichloroacetic Acid (mg/l)
Liver Function

SatisfactoryAbnormalOther
Reference:

Blood Lead (Female Upper limit 30 ug/dL; Male Upper limit 50 ug/dL), Haemoglobin (Female More than 11.5g%, Male More than 13.5g%)
Urine Manganese Upper Limit 50.01 ug/L

Urine Arsenic Upper Limit 300.01 ug/L

Blood Cadmium (Less than 5.01 ug/L), Urine Beta 2 Microglobulin (Less than 288 ug/gm Creatinine)

Urine Mercury Upper Limit 50.1 ug/L

Urine Trans, Trans-Muconic Acid 1.6mg/gm Creatinine

Urine Trichloroethylene (Exposure to Trichloroacetic Acid) Upper Limit 100mg/L
Presence of deterioration of results compared with previous tests (if any):

No deteriorationNo significant deteriorationMild deteriorationSignificant deteriorationBaseline. Health risks was discussed with patient.
Physician Comments
The abovementioned has met the requirements stipulated by the Workplace Safety and Health Act, Statutory Medical Examinations Regulations and is certified FIT TO WORK with:
The abovementioned has not met the requirements stipulated by the Workplace Safety and Health Act, Statutory Medical Examinations Regulations and is certified UNFIT TO WORK with:
Validity

6 Months1 Year3 Years6 Months for Lead1 Year for Mercury1 Year for Cadmium1 Year for Manganese1 Year for Benzene3 Years for Silica1 Year for ArsenicOther
Dr Gregory Chan Chung Tsing, Senior Specialist Occupational Health Physician and Designated Workplace Doctor MCR M06367C

Clear
Date

DayMonthYear
Date
Time

Hour Minutes

AM/PM Option
Should be Empty:

Rows	Satisfactory	Abnormal	Notes on Abnormalities
Eyes
ENT
Cardiovascular
Respiratory
Neurological
GIT
Skin
Psychiatric
Others

Rows	500HZ	1KHZ	2KHZ	3KHZ	4KHZ	6KHZ	8KHZ
RIGHT AC
LEFT AC
RIGHT BC
LEFT BC

Rows	Satisfactory	Abnormal	Details
Blood Lead, Haemoglobin
Urine Manganese
Urine Mercury
Urine TTMA
Blood Cadmium, Urine B2Microglobulin
RBC Cholinesterase
Plasma Cholinesterase
Chest xray
Otoscopy of Ears
Urine Arsenic
Others

STATUTORY MEDICAL EXAMINATION FORM

TO BE FILLED BY DOCTOR ONLY