Revised 6/12 Instructions to the Assignee 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 assignmen t-related benefits, premiums or provisions until this clearanceis obtained and reported to HR. Please follow the steps o utlined 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.MEDICAL PACKET HR STATEMENT- The Human Resource Representative should complete and this form may be used as the fax/email cover sheet when forwarding the Protocol results. 2.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 resultsforwarded for evaluation . 3.PHYSICAL EXAMINATION RECORD – The examining physician must complete this three (3) page docum ent comple te with sig nature.4.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 complete d questionnair e with this packet. Your name MUSTbe written on each page of the Physical Examination Record as well as Medical Questionnaire. 5.IMMUNIZATION REQUIREMENTS-Complete this form and acknowledge consent. The examining physician MUSTsign the form indicating you have had the required vaccinations or you will be required to provide a copy of your vaccination records. Each vaccination should have a date of last receipt or a statement by the physician. 6.MALARIA CHEMOPROPHYLAXIS COMPLIANCE REQUIREMENTS- Please read, sign and return this form if included with your protoco l. 7.MEDICAL AUTHORIZATION RELEASE FORM –Please read, sign and return this form. The completed packet should be sent by fax to: +1-240-813-2774, or send scanned copies of the packet including the HR Statement Form via email to: [email protected].This should come DIRECTLY from the physician’s 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 Representa tive for updates on your medical clearance .
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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 anyassignment-related benefits, premiums or provisions until this clearance is 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.
MEDICAL PACKET HR STATEMENT- The Human Resource Representative should complete
and this form may be used as the fax/email cover sheet when forwarding the Protocol results.
2.
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 for evaluation.
3. PHYSICAL EXAMINATION RECORD – The examining physician must complete this three (3)
page document complete with signature.
4. 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 with this packet. Your name MUST be written on each page of the PhysicalExamination Record as well as Medical Questionnaire.
5. IMMUNIZATION REQUIREMENTS- Complete this form and acknowledge consent. The
examining physician MUST sign the form indicating you have had the required vaccinations or you
will be required to provide a copy of your vaccination records. Each vaccination should have a date of
last receipt or a statement by the physician.
6. MALARIA CHEMOPROPHYLAXIS COMPLIANCE REQUIREMENTS- Please read, signand return this form if included with your protocol.
7.
MEDICAL AUTHORIZATION RELEASE FORM – Please read, sign and return this form.
The completed packet should be sent by fax to: +1-240-813-2774, or send scanned copies of the packet
including the HR Statement Form via email to: [email protected]. This should come DIRECTLY from
the physician’s office.
The company reviews and makes the final determination regarding your medical clearance for internationalassignments. Notification of determination is provided to the Human Resources Department.
Contact your HR Representative for updates on your medical clearance.
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: NIGERIA 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 when individual is over 55 years of age or otherwise indicated by exam
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 medicallyqualified to be hired.
No further evaluation:
Needs further evaluation:
Additional Comments:
Has examinee been counseled regarding findings and recommendations? Yes No
Will this examinee’s rating change in the next six months? Yes No
_____________________________________________________________________________________5. List any hospitalization, major illnesses, injuries, surgeries or other conditions (physical or psychological) that you
have EVER had along with the date: _ _____________________________________________________________________
I certify that the foregoing statements are true to the best of my knowledge. I understand that leaving out or misrepresenting the facts calledfor in this questionnaire may be the cause for refusal of employment or termination from the company. I hereby authorize the company toinvestigate 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 ofHalliburton and Associated Companies. It is not a physical examination of the type given by a physician to assess the state of my health andit 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 anadverse effect of workplace exposures.
I understand that the examining physician / medical staff and the Halliburton Medical and Disability Department will disclose, in writing, tome and appropriate Halliburton safety and health personnel any findings which, in the physician’s opinion, indicate any adverse effect ofoccupational exposure or pre-existing physical condition which precludes exposure to specific toxic materials or physical hazards.
Routine: Measles/Mumps/Rubella (MMR) Initial 1 to 2 doses.*
Hepatitis A Two doses lifetime.
Hepatitis B Three doses lifetime.
VaricellaTwo doses or acquired
immunity (previous illness).
PneumococcalOver age 65; then every 5
Years.
TyphoidOral every 5 years;
Injection every 2-3 years.
Meningococcal Meningitis Under age 55 every 5 years;Over age 55 every 10 years.
Yellow Fever** Every 10 years.
* Depending on the country assignment a booster may be required additionally. Please talk with the examining physician.
** Required for travelers arriving from the following countries: Angola, Argentina, Benin, Bolivia, Brazil, Burkina Faso, Burundi, Cameroon, Central African
List the prescription to be taken for MALARIA prevention (required): ____________________________
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, agreed to receive any that are needed, and attest, to my knowledge, the
information is accurate.
Assignee’s Signature: Date:
I attest that the above named person is current on all the required vaccinations indicated above and any additionanecessary vaccinations for the county in with they will be working/traveling.
Employee Statement of Understanding and Compliance
Name: Employee ID:
Country Assignment:
I understand that Halliburton, and its associated companies, (“the Company”), are committed to a safe, healthy, and
productive workplace for all employees. We take very seriously the threat of illness or death presented by malaria.The Company has implemented a malaria control program with the stated goal of no cases of malaria among its non-immune populations. I also understand that this program applies to me because I am considered "non-immune” withrespect to malaria at the site(s)/in the location(s) where I am going. I have been provided with information about themalaria control program as it applies where I am going and if I have any questions about this program I understand that
I should seek guidance from a qualified medical professional.
I further understand and agree that:
1. It is a condition of my assignment in/travel to a malarious location that I take an approved malariachemoprophylaxis (medication designed to help prevent me from contracting malaria if bitten by a mosquitocarrying the parasite that causes the disease). The Company has advised me that the malaria chemoprophylaxiscurrently acceptable include Malarone, Doxycycline, Mefloquine (Lariam), or other medication at least as
effective as one of these three, taken according to a prescribed treatment regimen. Saverin (combination ofchloroquin and proguanil) is not as effective in preventing malaria infection as other available alternatives and notan acceptable malaria chemophrophylaxis for work locations in malarial areas.
2. I have been advised to consult a travel medicine professional with questions I may have about the side effects thatmay be inherent in taking malaria chemoprophylaxis.
3. I am subject to unannounced, random and periodic testing to determine my compliance with the requirement that Itake approved malaria chemoprophylaxis as described above and that I am required, as a part of this testing, to
provide, when/where instructed, a urine sample for laboratory verification of my use of an approved malariachemoprophylaxis according to the prescribed treatment regimen.
4. If I refuse to submit to a test or if a medical review of the laboratory analysis of my urine specimen does not
indicate that I am taking an approved malaria chemoprophylaxis, I may be declared unfit for work in a malariouslocation and may be removed from my assignment and/or terminated by the Company.
5. Any problems or disputes arising from or in any way related to this Acknowledgement will be resolved exclusivelythrough the Halliburton Dispute Resolution Program which contains binding arbitration as its last step.
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 drugand /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 isalleged to be legally liable in conjunction with the physical evaluation, or the drugand/or alcohol testing.