Appendix 1

INITIATION OF APPEAL FORM

(Appeal is to be made within 2 weeks from the certification date)

Name of Foreign Worker: _______________________________________________

Foreign Worker Code: __________________________________________________
Name of Registered Employer:___________________________________________
Examination Date: _________________________
(The date when the above foreign worker was examined)

Certification Date: _________________________

(The date when the above foreign worker was certified)

Disease / Condition: _____________________________________________

(The reason for the unsuitability of the above foreign worker at the time of certification)

Decision with regards to appeal by the employer for the above foreign worker?
(Please tick at Accept column if appeal is accepted and you wish to carry out further investigations or
tick at Reject column if you do not wish to proceed with the appeal.)

ACCEPT
REJECT (Please state the reason if you reject the appeal):
______________________________________________________________________

Checklist for Accepted Appeal: (Please tick for each column)

Appeal Form (Compulsory)
Commitment Letter (Compulsory)
Request for Audit of repeat CXR.
Date of CXR sent to Medical Dept.: _________
Further Investigations that need to be done: (Please state the investigations)
_____________________________________________________________________
_____________________________________________________________________

Signature of Examining Doctor: _________________ Clinic Stamp: ____________

Name of Examining Doctor: _____________________________________________
(The examining doctor is the doctor who certify the above foreign worker)

Doctor Code: ________________________ Date of Appeal: ___________________

(This form is to be filled up by the examining doctor when the registered employer submits an appeal. The
filled-up form is to be faxed to FOMEMA. Fax No: 03-27828773 / 03-27828774)

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Appendix 4

APPEAL FORM
Date

To

Employer

The Appeal Committee

FOMEMA Sdn. Bhd.
:

Correspondence Address

Tel No :

(H)

(O)

(H/P)

(Fax)

Name of Employee (Foreign Worker)

Workers Code

Workers Passport no.

Country of Origin

I ________________________________, the employer of the above-mentioned employee who

has been certified unsuitable for employment after undergoing a medical examination at Clinic

____________________________________________________due to the following reasons

_____________________________________________________________________________________
I would like to request for a second medical examination to be conducted by the initial examining doctor.
I acknowledge that the decision of the Appeal Committee of FOMEMA Sdn Bhd shall be final and agree
unreservedly to abide by it. I undertake to hold FOMEMA Sdn Bhd harmless from any loss or liability
arising from this appeal including amongst other things like the spread of any infectious/communicable
diseases by the said employee and further agree to indemnify and keep FOMEMA Sdn Bhd and /or its
directors, shareholders and employees indemnified from any loss or liability arising from this appeal.
I undertake to bear any and all cost of this appeal and acknowledge that this appeal process may take up
to four (4) weeks from the time of its submission.

_________________
Authorized signature
Name : __________________
NRIC

: __________________

Employers Stamp (For Company only): ____________

(This form is to be filled up by the registered employer and verified by examining doctor. The filled-up form
is to be faxed to FOMEMA. Fax No: 03-27828773 / 03-27828774)

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Appendix 5

Dr.
.
Vice President of Medical
Medical Department
FOMEMA Sdn. Bhd.
(Attn:___________________________)

Tel:
Fax:

03-27828777
03-27828773 / 27828774

Dear Sir,
DECLARATION VERIFYING THE IDENTITY OF THE WORKER
Workers Name: ..
Worker Code: Passport No.: ..
I, Dr. . (APC No. ) of the abovementioned clinic and solemnly and sincerely declare that I have verified the identity of the abovementioned foreign worker with his/ her passport as well as checked his/ her height: ..,
weight:. and other physical distinguished marks (if any) .
...
I also declare that I have personally conducted further investigations on this foreign worker based
on FOMEMAs appeal procedure.
I make this solemn declaration conscientiously believing the same to be true.

..
Signature of Doctor

.
Date specimen / X-ray taken

.....
Clinic Stamp

Date of examination

*Note: Please attach medical report/ details of medical examination

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Appendix 6
COMMITMENT LETTER
Date
To
Employer
Address
Tel No :

:
: Vice President of Medical
:
:
: (H)
(H/P)

Name of Foreign Worker

Worker Code
:
Workers Passport No.
Country of Origin

(O)
(Fax)

:
:
:

I/We ____________________________, the employer of the above-mentioned foreign worker,

acknowledge
that
I/we
am/are
aware
of
his/her
medical
condition:
_____________________________________________________________________and duly
undertake full responsibility for him / her.
I/We declare that in spite of the foreign workers medical condition described above, I/we wish to
employ/continue employing him/her as __________________________ and his/her duties are as
follows:1)___________________________________________________________________________
2)___________________________________________________________________________
3)___________________________________________________________________________
In light of the medical condition described above I/we confirm and assure FOMEMA that I/we will
not assign him/her any tasks that would aggravate the foreign workers medical condition
described above and put him/her/others health at risk. Additionally, I confirm that I/we will bear
any and all cost relating directly or indirectly towards the medical management of his/her medical
condition.
I/We confirm that FOMEMA shall not be held responsible in any manner whatsoever, arising out
of FOMEMAs certification of the above named foreign worker as being suitable for employment
in Malaysia despite the medical condition described above. I/we further undertake to hold
FOMEMA harmless from any loss or liability arising from this decision and agree to indemnify and
keep FOMEMA from any loss or liability arising from this decision.

_________________
Authorized signature
Name : __________________
NRIC : ___________________
Employers Stamp (For Company only): ____________
(This form is to be filled up by the registered employer and verified by examining doctor. The filled-up form
is to be faxed to FOMEMA. Fax No: 03-27828773 / 03-27828774)

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Appendix 17

To

1.

Consultant Radiologist of FOMEMA SDN. BHD.

From :

____________________

Date :

_________________

Please find attached X-Ray film (s) of Foreign Worker:

2.

1.1

Name

:_________________________________

1.2

Worker Code

:_________________________________

1.3

X-ray Film (s) dated

:_________________________________

Reason for Despatch to XQCC:

Appeal

3.

Request for comparison & audit x-ray film and reports:

1st X-ray dated

:__________________________________________

2nd X-ray dated :

__________________________________________

NOTE:

The filled-up form is to be attached to the X-ray film and also faxed to Medical
Department, UNITAB MEDIC Sdn. Bhd. (FOMEMA Sdn. Bhd.)
Fax no: 03-27828773 or 03-27828774