Appendix 4

APPEAL FORM

Date :
To : The Appeal Committee
FOMEMA Sdn Bhd
Employer :
Correspondence Address :
Tel No : (H) (O)
(H/P) (Fax)
Name of Employee (Foreign Worker) :
Worker s Code :
Worker s Passport no. :
Country of Origin :
I ________________________________, the employer of the above-mentioned employee
who has been certified unsuitable for employment after undergoing a medical exam
ination 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 f
rom any loss
or liability arising from this appeal including amongst other things the spread
of any
infectious/communicable diseases by the said employee and further agree to indem
nify and
keep FOMEMA Sdn Bhd and /or its directors, shareholders and employees indemnifie
d from any
loss or liability arising from this appeal.
I undertake to bear any and all cost of this appeal and acknowledge that this ap
peal process
may take up to four (4) weeks from the time of its submission.
Authorized signature
Name : __________________
NRIC : __________________
In order for FOMEMA to initiate the appeal process, please send the original cop
y of this
document as soon as possible.
Version No: AP Version 2.0
Appendix 6
COMMITMENT LETTER
Date :
To : Medical Division, Pantai FOMEMA & Systems Sdn Bhd
Employer :
Address :
Tel No : (H) (O)

(H/P) (Fax)
Name of Foreign Worker :
Worker s Code :
Worker s Passport no. :
Country of Origin :
I/we ____________________________, the employer of the above-mentioned foreign w
orker,
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 worker s medical condition described abo
ve, I/we wish
to employ/continue employing him/her as a ___________________________________ an
d
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 worker s medica
l condition
described above and put him/her/others health at risk. Additionally, I confirm t
hat 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 FOMEMA s certification of the above named foreign worker as being suitable for
employment
in Malaysia despite the medical condition described above. I/we further undertak
e 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 : ___________________
Version No: AP Version 2.0
Appendix 5
Dr .
.
Chief Medical Officer
FOMEMA Sdn Bhd
Lot G1-G10, Level 3, Block G(Central)
Pusat Bandar Damansara Tel: 03-20946188/ 20941971
50490 Kuala Lumpur Fax: 03-20940969/ 20954308
(Attn:___________________________)
Dear Sir,
DECLARATION VERIFYING THE IDENTITY OF THE WORKER
Worker Name: ..
Worker Code: Passport: ..
I, Dr. . (APC No. ) of
the above-mentioned clinic and solemnly and sincerely declare that I have
verified the identity of the above-mentioned 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 of FOMEMA 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
Version No: AP Version 2.0
Appendix 1
INITIATION OF APPEAL FORM
Note: Appeal is to be made within 2 weeks of the certification date
Name of Foreign Worker: ___________________________________________
Foreign Worker s Code: ______________________________________________
Name of Employer: ________________________________________________
Examination Date: ____________________
(Pleasestate the datewhenthe above foreignworkerwas examined)

Certification Date: _____________________

(Please state the date when you(theexaminingdoctor) certifiedtheaboveforeign wor
keras
unsuitable during the cur
rrent medicalexamination)
Disease /Condition: _____________________
(Please state the reason for theunsuitability for the above foreign worker at th
etimeof
certification)

Do you accept or reject the application of employer to appeal for the above
foreign worker based on guidelines for appeal process?
(Tickvatthe Accept Box ifyou acceptthe appealandwishtocarryout further investigation
s,
or tickvatthe RejectBox if youdonot wish toproceedwiththeappeal.)

ACCEPT
REJECT (Pleasestatethe reasonifyou reject the appeal): _________________

If you accept the appeal, please tick (v

) the following:

APPEAL FORM (Compulsory)

COMMITMENT LETTER (Compulsory)
REQUEST FOR AUDIT OF REPEAT X-RAY
Date Repeat X-ray sent to XQCC: ___________

INVESTIGATIONS TO BE DONE:
Signature of Doctor: _________________ CLINIC STAMP:
Name of Examining Doctor: ________________________________
(The doctoristheexamining doctorwhocertifiedtheabove foreign worker)
Doctor s Code: ________________________ Date of appeal: __________________
This form is to be filled up by the examining doctor when the employer submits a
n
appeal. The filled-up form is to be faxed to Pantai FOMEMA & Systems Sdn Bhd.
Fax no: 03-20940969 or
03-20954308
Version No: AP Version 2.0
Appendix 17

To : XQCC MANAGER,
From : ____________________
Date : _________________

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

1.1 Name :_________________________________
1.2 Worker Code :_________________________________
1.3 X-ray Film (s) dated :_________________________________
2. 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
Pantai FOMEMA & Systems Sdn Bhd.
Fax no: 03-20940969 or

03-20954308
Version No: AP Version 2.0