BORANG PEMERIKSAAN PERUBATAN Tarikh Pemeriksaan :

Examination Date
Medical Examination Form Tandatangan Doktor :
Doctor's Signature
Page: 2/2
Cop Klinik :
Cancellation/ Refund before 07/05/2021 Clinic's Stamp

Kod Pekerja: W84S273386

Worker's Code
Nama Pekerja: SANIAH No. Passport: B9024582 MAID ONLINE
Worker's Name Passport No.
Jantina: FEMALE Negara Asal: INDONESIA
Gender Country of Origin
Tarikh Lahir: 16-03-1978 Tarikh Pendaftaran: 08-04-2021
Date of Birth Date of Registration
Telefon Majikan: 0122089702 Majikan: ZAKUAN SHAH BIN
Employer Contact No. Employer KAMARULZAMAN
No. Telefon Doktor: 0362012202 No. Telefon X-Ray: 0362012202
Doctor Telephone No. X-Ray Telephone No.
Sah Sehingga: 07/05/2021 Kod Majikan: E6EZ010371
Valid Until Employer's Code

ID Trans: 20210408759082 Tarikh Pemeriksaan:

Trans ID Examination Date
Kod Doktor: D34A000052 Kod Pekerja: W84S273386 Jantina: FEMALE
Doctor's Code Worker's Code Gender
Nama Doktor: ARASUNAYAGAM A/L SELVANAYAGAM No. Passport: B9024582
Doctor's Name Passport No.
Nama Klinik & KLINIK DESA SRI HARTAMAS Nama Pekerja: SANIAH MAID ONLINE
Alamat: 31 PLAZA CRYSTALVILLE 1 Worker's Name
Clinic Name & JALAN 23/70A DESA SRI HARTAMAS Sah Sehingga: 07/05/2021
Address 50480 SRI HARTAMAS KUALA LUMPUR
Valid Until

No. Telefon : 0362012202 No. Telefon Majikan : 0122089702 Tandatangan Doktor : Cop Klinik :
Telephone No. Employer Contact No. Doctor's Signature Clinic's Stamp

MAID ONLINE

Workers Name : SANIAH

Workers Code : W84S273386
Trans ID : 20210408759082
Nama Pekerja: SANIAH
Worker's Name
Kod Doktor: D34A000052 No. Passport: B9024582
Doctor's Code Passport No.
Kod Makmal: L14D000003 Kod Perkerja: W84S273386 Jantina: FEMALE
Laboratory's Code Worker's Code Gender
Nama Makmal & DUNIA WELLNESS & Nama Klinik & KLINIK DESA SRI HARTAMAS
Alamat: LABORATORIES SDN BHD Alamat: 31 PLAZA CRYSTALVILLE 1
Laboratory's 2-G-10, GROUND LEVEL Clinic Name & JALAN 23/70A DESA SRI
Name & Address WISMA RAMPAI Address HARTAMAS
JALAN 34/26 50480 SRI HARTAMAS KUALA
TAMAN SRI RAMPAI LUMPUR
53300 SETAPAK KUALA
LUMPUR

No. Telefon: 0361780957 Sah Sehingga: 07/05/2021 No. Telefon Majikan: 0122089702
Telephone No. Valid Until Employer Contact No.
Tarikh Pemeriksaan: Tandatangan Doktor : Cop Klinik :
Examination Date Doctor's Signature Clinic's Stamp
Workers Name : SANIAH
Workers Code : W84S273386
Trans ID : 20210408759082

Nama Pekerja: SANIAH MAID ONLINE

Worker's Name
Kod X-Ray: X24K000075 Kod Pekerja: W84S273386 Jantina: FEMALE
X-Ray's Code Worker's Code Gender
No. Pasport B9024582
Passport No.
Nama Fasiliti KLINIK DESA SRI HARTAMAS Nama Klinik KLINIK DESA SRI HARTAMAS
X-Ray & Alamat: NO.31 PLAZA CRYSTAL VILLE 1 & Alamat: 31 PLAZA CRYSTALVILLE 1
X-Ray's Facility JALAN 23/70A, DESA SRI HARTAMASClinic Name JALAN 23/70A DESA SRI
Name & Address 50480 SRI HARTAMAS KUALA & Address HARTAMAS
LUMPUR 50480 SRI HARTAMAS KUALA
LUMPUR

No. Telefon: 0362012202 Sah Sehingga: 07/05/2021 No. Telefon Majikan: 0122089702
Telephone No. Valid Until Employer Contact No.
Tarikh Pemeriksaan: Tandatangan Doktor : Cop Klinik :
Examination Date Doctor's Signature Clinic's Stamp
 Page: 1/2

PENTING/IMPORTANT
Tempoh sah laku Borang Pemeriksaan Perubatan ini adalah 30 hari dari tarikh pendaftaran.
The validity of the Medical Examination Form is 30 days from the date of registration.
Berkuatkuasa pada 01 Januari 2020, sebarang permohonan untuk pembatalan dan tuntutan bayaran balik pendaftaran
pekerja asing hanya dibenarkan dalam tempoh sah laku Borang Pemeriksaan Perubatan.
Effective on 01st January 2020, any request for cancellation and refund for foreign worker's registration only will be
entertained within validity period of the Medical Examination Form.
Sebarang permohonan pembatalan pendaftaran/bayaran balik adalah tertakluk kepada yuran perkhidmatan sebanyak RM
25.0 bagi setiap pekerja asing.
Any request for cancellation of registration/refund will be subjected to service fees of RM 25.0 for each worker.
Sila pastikan semua maklumat di atas adalah tepat.
Please ensure that all information stated above is correct.
Sila pastikan Borang Pemeriksaan Perubatan ini dibawa bersama passport asal untuk pemeriksaan perubatan.
Please bring along this Medical Examination Form together with the original passport for medical examination.
FOMEMA tidak bertanggungjawab ke atas pembayaran sekiranya pemeriksaan perubatan dijalankan oleh klinik selain
daripada yang tersebut di atas.
FOMEMA will not responsible for any payment if the medical examination is carried out by medical facilities other than
named above.

Prosedur Pemeriksaan Perubatan

(Untuk Perhatian Majikan)
1. Pekerja asing hanya dibenarkan membuat pemeriksaan perubatan dan X-Ray di Klinik/Pusat X-Ray seperti yang tercatat
dalam borang ini dalam masa 30 hari dari tarikh pendaftaran pekerja asing di FOMEMA.
2. Panel doktor dan pusat X-Ray FOMEMA TIDAK DIBENARKAN untuk menjalankan sebarang pemeriksaan perubatan
sekiranya pengesahan identiti dengan passport asal tidak dapat dilakukan.
3. Pekerja asing dikehendaki menjalani pemeriksaan fizikal oleh doktor terlebih dahulu sebelum menjalankan pemeriksaan X-
Ray.
4. Sila pastikan tarikh pemeriksaan doktor telah diisi oleh doktor di dalam borang ini selepas pemeriksaan fizikal dijalankan.
Majikan juga perlu menyimpan 'Salinan Majikan' borang ini sebagai rujukan.
5. Status keputusan pemeriksaan perubatan pekerja boleh disemak dalam masa 10 hari bekerja dari tarikh pemeriksaan
perubatan dijalankan oleh doktor melalui:
Laman Web : www.fomema.com.my
Menghubungi Pusat Perkhidmatan Pelanggan FOMEMA di talian 03-27828777
6. FOMEMA akan menghantar rekod keputusan pemeriksaan perubatan pekerja asing ke Ibu Pejabat Jabatan Imigresen,
sehari selepas mendapat pengesahan status perubatan pekerja asing daripada doktor yang memeriksa (kecuali kes-kes
yang memerlukan siasatan lanjut).
7. Status keputusan pemeriksaan perubatan pekerja asing dari FOMEMA hanya akan berada di Jabatan Imigresen selama
180 hari dari tarikh pemeriksaan perubatan dijalankan. Medical Examination Procedure (For Employer's Attention)

Medical Examination Procedure

(For Employer's Attention)
1. The foreign worker shall only be allowed to undertake the medical and X-Ray examination at the Clinic /X-Ray Facility
printed in this form within 30 days from the date of registration of foreign worker at FOMEMA.
2. FOMEMA's panel doctors and X-Ray Facilities is NOT ALLOWED to carry out any medical examination if the identity of the
foreign worker cannot be verified against the original passport.
3. The foreign worker must undergo the physical examination by the doctor before undergoing the X-Ray examination.
4. Please ensure that the date of the medical examination is duly filled by the doctor in this form.
The employer should retain the 'Employer's Copy' of this form as reference.
5. The status of medical examination result can be obtained within 10 working days from the date of the medical examination
by the doctor through:
Website : www.fomema.com.my
Contact FOMEMA's Customer Service Department : 03-27828777
6. FOMEMA only transmits the result of the foreign worker's medical examination to the Immigration Department of Malaysia
on the following day after the foreign worker has been certified by the doctor (except for the cases that require further
investigation).
7. The status of foreign worker's medical examination result from FOMEMA will only be available at the Immigration
Department of Malaysia for 180 days from the date the medical examination was carried out.