Strictly Confidential
Employee Health Declaration Form
As an employer, OSK Group Berhad or any of its subsidiaries is responsible for your health, safety
and welfare whilst at work. Therefore, it is important that we are aware of any condition,
medical or otherwise, which may have an impact on your wellbeing at workplace. Appreciate
your assistance to complete the questionnaire attached to ensure you are properly
accommodated in the workplace.
1) Are you currently receiving Yes No If yes, please advise the current
treatment of any kind? status and your practitioner’s
contact.
• From a Doctor /
• From a Physiotherapist /
• From a Chiropractor
• Other health practitioner (ie Herbalist,
Acupuncturist, Psychologist etc).
/
2) Have you ever been diagnosed or If yes, when were you diagnosed?
diagnosed for: Please advise the current status.
• High or low blood pressure /
• Heart disease or heart attack /
• Asthma or other respiratory illness /
• Chronic bronchitis /
• Fits or epilepsy /
• Anxiety /
• Slipped disc or back surgery /
• Diabetes /
• Cancer /
• Any other critical illness that requires
long term medication /
3) Are you / Have you: If yes, when was the last time?
Please advise the reason and
current status.
• Ever been hospitalised /
• Ever had a surgery /
• Been away from work for longer than 1
month for an injury, accident or illness /
Page 1|2
Strictly Confidential
Employee Health Declaration Form
• I certify that all my information provided by me is at the time of completion true and
correct to the best of my knowledge. Should any factors relating to my health and well-
being change at any time in the future, I agree to inform all relevant parties immediately
and understand this may impact on the duties I am able to perform in my employment.
• I understand that failure to disclose any medical conditions or injuries may result in
dismissal from my employment.
12/10/2024
AHMAD AZHARI BIN AHMAD BADARUDDIN
Name: Date:
Signature:
Page 2|2
