MEDICAL DECLARATION FORM
[ESPERANZA]
Demographic Info
Maklumat demografik
1. Full Name *
Nama Penuh
ABDUL WAFI BIN FAUZI
2. NRIC / Passport No *
No. IC / Passport
970809335057
3. Company *
Syarikat
ELSA ENERGY SDN BHD
4. Position *
Jawatan
DRONE SOLUTION ENGINEER / PILOT
5. Date of Birth *
Tarikh Lahir
8/9/1997
6. Sex *
Jantina
Male (Lelaki)
Female (Perempuan)
7. Blood Group *
Jenis Darah
A+
B+
AB+
O+
Other
8. Allergies *
Alahan
Yes / Ya
No / Tidak
9. Embarkation Date *
Tarikh berangkat ke Offshore
2/6/2025
Medical History
Sejarah Kesihatan
10. Do you have currently or history of any medical conditions? *
Adakah anda menpunyai sebarang masalah kesihatan?
Yes / Ya
No / Tidak
Prescription Medication
Preskripsi Ubat
11. Do you have any prescribed medication from Doctor? *
Adakah anda mempunyai preskripsi ubat dari Doctor?
Yes / Ya
No / Tidak
12. I declare that I am not aware of any medical condition that would affect my ability to
work on this offshore facility. *
Saya mengisytiharkan bahawa saya tidak mengetahui sebarang keadaan perubatan yang akan
menjejaskan keupayaan saya untuk bekerja di kemudahan luar pesisir ini
Agree / Setuju
13. I understand that it is my responsibility to notify Sapura Drilling of any change to my
health status which could affect me while carrying out my duties offshore. *
Saya faham bahawa adalah menjadi tanggungjawab saya untuk memaklumkan Sapura Drilling tentang
sebarang perubahan pada status kesihatan saya yang boleh menjejaskan saya semasa menjalankan
tugas saya di luar pesisir.
Agree / Setuju
Emergency Contact Details (Contact 1)
Maklumat Talian Kecemasan (Panggilan 1)
14. Name *
Nama
FAUZI BIN YAZID
15. Address *
Alamat
SINGGAHAN DESA PT 564 JALAN MASJID KG PAUH 17000 PASIR MAS KELANTAN
16. Contact Number (with country code) *
No. Tel H/P (dengan kod negara)
+60129836292
17. Relationship *
Hubungan
FATHER
Emergency Contact Details (Contact 2)
Maklumat Talian Kecemasan (Panggilan 2)
18. Name
Nama
Enter your answer
19. Address
Alamat
Enter your answer
20. Contact Number (with country code)
No. Telefon (dengan kod negara)
Enter your answer
21. Relationship
Hubungan
Enter your answer
End of Form
Borang Tamat
22. Data Verification *
Pengesahan Maklumat
I hereby acknowledge that the above information is correct / Saya mengaku bahawa semua mak‐
lumat di atas adalah benar.
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