TATA KERJA ORGANISASI
DOC OWNER :HSSE-HEA DOC NUMBER :MHK-COMP-TKO-HSE-MED-0005
TITLE :HSE 06-610 MEDICAL CHECK- EFFECTIVE DATE :02-09-2022
UP AND FITNESS TO WORK
EXPIRED DATE :02-09-2025
This document is the property of PT PERTAMINA HULU MAHAKAM (PHM). It must not be stored, reproduced or disclosed to others without written authorisation from PT PHM.
L. APPENDIX XII: BRIEFING NOTE / SELF ASSESSMENT FOR VISITOR
Briefing Note/Self Assessment Statement for Visitor
BRIEFING NOTE
When visiting an offshore and/or remote
installation, factors such as the mode of
travel, the environment in which it is located,
J0292024 - Sulaiman RASYID | Uncontrolled Paper Copy | CMS | 06-12-2022 4:18 PM
and its sheer physical structure interms of
size, numerous stairways, over sea
walkways, etc. require of the individual a
certain degree of alertness, physical
mobility, coordination and stamina.
Designated offshore and/or remote
employees are medically assessed regularly
during their employment to ensure the above
requirements are fulfilled, and the same
protection is extended to you.
Detailed below are medical conditions that
may require particular consideration or the
arrangement of special provisions to ensure
your personal well being during your visit.
You must report to the medical personnel on
board once you get on board should any of
these conditions apply to yourself, or should
you have any questions arising from the list.
Medical confidentiality is guaranteed.
Medical conditions, which may require
special consideration, include:
current infections,
significant impairment of vision,
significant impairment of hearing,
impairment of mobility (especially steps),
fear of heights, confined space or flying,
diabetes mellitus,
epilepsy, fainting attacks, episodes of
unsteadiness,
cardiac or circulatory problems, including
pacemakers,
chest pain or shortness of breath on
exertion,
asthma,
peptic or duodenal ulceration,
colostomy or ileostomy,
significant prostate problems,
REVISION NO :1
PAGE :99 of 108
CATATAN TAKLIMAT
Ketika mengunjungi lokasi lepas pantai dan/atau
lokasi terpencil, faktor-faktor seperti moda
perjalanan, lingkungan sekitar dan struktur fisik
dalam bentuk ukuran, jumlah anak tangga, jalan di
atas laut, dll membutuhkan derajat kewaspadaan
tertentu, mobilitas fisik, koordinasi dan stamina.
Kondisi kesehatan pegawai yang ditempatkan di
lepas pantai dan/atau lokasi terpencil diperiksa
secara teratur untuk memastikan semua ketentuan
terpenuhi, perlakuan yang sama juga diterapkan
kepada anda.
Hal-hal di bawah ini adalah kondisi medis yang
mungkin membutuhkan perhatian atau ketetapan
khusus, untuk memastikan kebaikan anda selama
kunjungan.
Anda harus melapor ke petugas medis setempat
pada kesempatan pertama berada di lokasi kerja
PHM, terutama bila anda mengalami salah satu atau
lebih kondisi medis yang tercantum, atau ada
pertanyaan yang ingin disampaikan. Kerahasiaan
Medis dijamin.
Kondisi medis, yang mungkin memerlukan
pertimbangan khusus, termasuk:
infeksi yang sedang aktif,
kerusakan penglihatan yang bermakna,
kerusakan pendengaran yang bermakna,
kelemahan dalam bergerak (terutama melangkah),
takut ketinggian, tempat tertutup, atau terbang,
kencing manis,
Ayan, serangan pingsan, atau ketidakkokohan,
penyakit jantung atau pembuluh darah, termasuk
pemakai alat pacu jantung,
nyeri dada atau sesak napas pada aktivitas
berlebihan,
asma,
tukak lambung (maag),
lubang usus buatan,
 TATA KERJA ORGANISASI
DOC OWNER :HSSE-HEA
TITLE :HSE 06-610 MEDICAL CHECK- EFFECTIVE DATE :02-09-2022
UP AND FITNESS TO WORK
EXPIRED DATE :02-09-2025
This document is the property of PT PERTAMINA HULU MAHAKAM (PHM). It must not be stored, reproduced or disclosed to others without written authorisation from PT PHM.
recent major surgery,
Pregnancy.
If you wear spectacles and your vision
without these is poor, you are advised to
carry a spare pair in case of loss or
breakage.
Finally, if you are taking regular medication,
J0292024 - Sulaiman RASYID | Uncontrolled Paper Copy | CMS | 06-12-2022 4:18 PM
ensure you bring an adequate supply in a
properly marked container.
If you require, assistance offshore, the
"Offshore Medic" will be pleased to help you.
I herewith declare that the medical
conditions, mentioned in the briefing note for
Visitors to Offshore and/or Remote
Installations, are not applicable to my
situation.
Date/ Tanggal: ___ / ___ / ____
DOC NUMBER :MHK-COMP-TKO-HSE-MED-0005
REVISION NO :1
PAGE :100 of 108
masalah prostat yang bermakna,
pembedahan besar yang baru saja dikerjakan,
kehamilan
Jika anda pemakai kacamata, dan penglihatan anda
buruk tanpa kacamata tersebut, anda disarankan
membawa kacamata cadangan jika terjadi
kehilangan atau kerusakan.
Akhirnya, bila anda menggunakan obat-obatan
secara teratur, pastikan anda membawa jumlah yang
cukup dalam tempat yang layak dan ditandai.
Bila dibutuhkan, petugas dan perawat lepas pantai
akan dengan senang membantu anda.
PERNYATAAN PENGUNJUNG
Dengan ini, saya menyatakan bahwa saya tidak
mengalami kondisi medis seperti yang tercantum
dalam catatan taklimat Kunjungan ke Lokasi Lepas
Pantai dan/atau Lokasi Terpencil di atas
Signature/ Tanda Tangan:_________________