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.
 BORANG PEMERIKSAAN PERUBATAN Tarikh Pemeriksaan :
Examination Date
Medical Examination Form Tandatangan Doktor :
Doctor's Signature
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Cop Klinik :
Cancellation/ Refund before 24/12/2022 Clinic's Stamp

Kod Pekerja: W7ED112022

Worker's Code
Nama Pekerja: DAKSHINAMOORTHY No. Passport: R1925365
Worker's Name VENKATESAN Passport No.
Jantina: MALE Negara Asal: INDIA
Gender Country of Origin
Tarikh Lahir: 29-05-1977 Tarikh Pendaftaran: 25-11-2022
Date of Birth Date of Registration
Telefon Majikan: 0162171786 Majikan: RESTORAN AL-RAFI SDN BHD
Employer Contact No. Employer
No. Telefon Doktor: 062883318 No. Telefon X-Ray: 062813333
Doctor Telephone No. X-Ray Telephone No.
Sah Sehingga: 24/12/2022 Kod Majikan: E6ER016202
Valid Until Employer's Code

ID Trans: 20221125805074 Tarikh Pemeriksaan:

Trans ID Examination Date
Kod Doktor: D15S000013 Kod Pekerja: W7ED112022 Jantina: MALE
Doctor's Code Worker's Code Gender
Nama Doktor: SELVA KUMARAN A/L SOCKALINGAM No. Passport: R1925365
Doctor's Name Passport No.
Nama Klinik & POLIKLINIK BANDAR Nama Pekerja: DAKSHINAMOORTHY VENKATESAN
Alamat: 33 - 35 JALAN BANDA KABA Worker's Name
Clinic Name & 75000 BANDAR MELAKA MELAKA Sah Sehingga: 24/12/2022
Address Valid Until

No. Telefon : 062883318 No. Telefon Majikan : 0162171786 Tandatangan Doktor : Cop Klinik :
Telephone No. Employer Contact No. Doctor's Signature Clinic's Stamp

VENKATESAN
Workers Name : DAKSHINAMOORTHY
Workers Code : W7ED112022
Trans ID : 20221125805074
Nama Pekerja: DAKSHINAMOORTHY VENKATESAN
Worker's Name
Kod Doktor: D15S000013 No. Passport: R1925365
Doctor's Code Passport No.
Kod Makmal: L15N000001 Kod Perkerja: W7ED112022 Jantina: MALE
Laboratory's Code Worker's Code Gender
Nama Makmal & NORTHERN MEDICAL Nama Klinik & POLIKLINIK BANDAR
Alamat: LABORATORY SDN BHD Alamat: 33 - 35 JALAN BANDA KABA
Laboratory's NO. 6, 6-1, JALAN PNBBU 5 Clinic Name & 75000 BANDAR MELAKA
Name & Address PUSAT NIAGA BUKIT BARU Address MELAKA
UTAMA
BUKIT BARU
75150 BANDAR MELAKA
MELAKA

No. Telefon: 062821016 Sah Sehingga: 24/12/2022 No. Telefon Majikan: 0162171786
Telephone No. Valid Until Employer Contact No.
Tarikh Pemeriksaan: Tandatangan Doktor : Cop Klinik :
Examination Date Doctor's Signature Clinic's Stamp
VENKATESAN
Workers Name : DAKSHINAMOORTHY
Workers Code : W7ED112022
Trans ID : 20221125805074

Nama Pekerja: DAKSHINAMOORTHY VENKATESAN

Worker's Name
Kod X-Ray: X35M000001 Kod Pekerja: W7ED112022 Jantina: MALE
X-Ray's Code Worker's Code Gender
No. Pasport R1925365
Passport No.
Nama Fasiliti MAHKOTA MEDICAL CENTRE Nama Klinik POLIKLINIK BANDAR
X-Ray & Alamat: NO 3 MAHKOTA MELAKA & Alamat: 33 - 35 JALAN BANDA KABA
X-Ray's Facility JLN MERDEKA Clinic Name 75000 BANDAR MELAKA MELAKA
Name & Address 75000 BANDAR MELAKA & Address
MELAKA

No. Telefon: 062813333 Sah Sehingga: 24/12/2022 No. Telefon Majikan: 0162171786
Telephone No. Valid Until Employer Contact No.
Tarikh Pemeriksaan: Tandatangan Doktor : Cop Klinik :
Examination Date Doctor's Signature Clinic's Stamp