Infectious Disease Prevention & Control Unit

Health Promotion and Disease Prevention Directorate

Form B - Application form for

Health Screening for Work Permit
Applicable for first time applicants coming from countries with
High Tuberculosis incidence doing Other Jobs;
(E.g. administrative, construction/manual workers, cleaners/housekeepers, footballers,
hairdressers/makeup artists, working in transport, delivery persons, security guards, laboratory
technicians working in a non-medical field (e.g. construction, chemicals, pharmaceuticals, etc))

CONFIDENTIAL

Please read the following instructions carefully

As a potential employee, applicants have a duty to provide the relevant information to the
Infectious Disease Prevention and Control Unit (IDCU) within the Health Promotion and
Disease Prevention Directorate. All medical and sensitive personal information applicants
provide, will be held in complete confidence by the Directorate.

Documentation

Employee will need to go to a private Medical Doctor for this form to be duly filled and to carry
out the required medical examination and tests as requested according to the job applying for.

All documentation should be in English.

The Directorate will only accept investigations from radiology clinics in Malta licensed by the
Superintendence of Public Health

Any abnormal results kindly forward a copy to IDCU on workpermit.idcu@gov.mt for the
necessary actions.

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 Section A: PERSONAL INFORMATION

1. Job applying for: _______________________________________________________

 1st time application  Change of job

2. What year did you start working in Malta?____________________________________

3. Details of Employee:

Surname (as it appears on passport):

Name (as it appears on passport):

Gender:

Date of Birth: Day: Month: Year:

Place of Birth:

Nationality:

ID/Passport Number:

Address in Malta:

Mobile:

Email:

List all the countries you have lived in for a period of 6 months or more:

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Detailed job description:
(Please see list in website)

4. Details of Employer:

Name of Employer:

Name of company (if applicable):

Email:

Mobile/Telephone:

Address:

I hereby declare that the information given in this application is true to the best of my
knowledge.

Employee’s Signature (applicant) Employer’s Signature

Date: __________________ ID number: ________________

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 Section B: HEALTH SCREENING

To be completed by the private Medical Doctor

It is important that employees are screened for relevant infectious diseases prior to their
initiation of employment.

Please note that it is MANDATORY that this section of the form is completed by ONE
(1) doctor only and the doctor’s contact telephone number and email address are
clearly written down.

Failure to comply with this will result in the application form NOT being processed.

1. Chest X-Ray


To be done locally in the PRIVATE SECTOR by some employees

• Employees who were born or who have lived for 6 months or more in a country reported
as High/Very High Risk for TB need to take a chest x-ray.
• Chest x-rays need to be taken within the last 6 weeks from the date of the application
form.
• Employees who are changing jobs, can present their previous chest x-ray if
this was taken within the past year. If the chest x-ray was taken more than 1
year ago, a repeat of chest x-ray is required.
• Important to fill in the date when chest x-ray was taken.
• If results show any abnormalities, please send a copy of the report with the
application form.
• A copy of the chest x-ray report must be attached with the application
form.

Requirement Results submitted Date taken

(Tick as Applicable)

CHEST X-RAY
 CXR Normal
*For applicants who are born or have spent 6 months or
more in a country reported as High/Very High Risk for TB  CXR Abnormal
by the World Health Organisation

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 2. Vaccines and Blood Investigations

• Important to duly complete the form, including dates for health screening investigations
and batch numbers for vaccinations.

POLIO / DIPHTHERIA
Full immunity is required
DATE:
1. 1 dose administered in MALTA IPV Boostrix

Repevax (Sanofi)

Imovax BATCH/LOT NUMBER

Dultavax

Revaxis

OR
DATE:
2. Poliovirus and Diphtheria Immune
immunity test
Non-immune

Should blood level show no immunity, applicant must receive one dose of vaccine.

MEASLES

DATES & BATCH NO.

Documented vaccinations  Records available
Records unavailable*

* If vaccination records unavailable or vaccine never taken, it is recommended that the applicant takes
1 dose of MMR vaccine.

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Covid-19

COVID-19 VACCINES

If COVID-19 vaccine was received, kindly tick accordingly

Comirnaty (Pfizer) DATE OF 2ND DOSE OF

1. Vaccines VACCINE

Spikevax (Moderna)

Vaxzevria (AstraZeneca)

Janssen (Johnson & Johnson*)

DATE OF BOOSTER VACCINE

2. Booster vaccine Received

Not received

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 Section C: INFORMATION FOR MEDICAL DOCTORS

All employees need to be examined to exclude symptoms of scabies, food and water borne
illnesses (gastroenteritis) and vaccine preventable diseases such as chickenpox and measles.

I declare that the employee is not suffering from the above-mentioned infectious
diseases.

I declare that the employee is showing no symptoms suggestive of active tuberculosis

(prolonged cough for more than 2 weeks; Haemoptysis; Fever; Weakness; Weight loss;
Night sweats; Chest pain).

I declare that I have vetted all the necessary investigations requested to apply for a work
permit and found

NO ABNORMALITIES.

ABNORMALITIES, that include; ___________________________________

_____________________________________________________________________

_____________________________________________________________________

Kindly inform employee/employer to send application to workpermit.idcu@gov.mt

together with a copy of the abnormal results to be followed up as necessary

Comments:

Doctor’s Name & Surname (in block letters): _____________________________________

Medical Council Registration No: __________________ Stamp

Mobile No: ___________________________________

Email address: ________________________________

Signature: ___________________________________

Kindly ensure that the details provided are all legible. Otherwise, the application will not be
processed. Only rubber stamps with legible information requested above will be accepted.
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 Section D: EMPLOYEE’S DECLARATION

Employee:

I declare that to the best of my knowledge, the information provided is correct. I

understand that approval for work permit is subject to successful completion of a
medical test and that any test as for which I have provided results may need to be
repeated.

Signature of employee: Date:

The personal data requested is being processed according to Article 27 (a) (i) of the Public Health Act, the General
Data Protection Regulation (EU) 2016/679 and the Data Protection Act 2018.

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