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FITNESS FOR TASK HEALTH ASSESSMENT

REFERRAL LETTER

To:

Attending Physician,

From:

Senior HSE Advisor - Occupational Health / Designate


, United Energy Pakistan

Dated:
Subject: Health Assessment of _Mohammad Fahad Kazalbash______
Dear Doctor,
Thank you for agreeing to perform a health assessment on this employee who is
working in UEP as
1. Remote worker (Field Based Technical Staff)
2. Professional driver
3. Office based Staff [Karachi or Field]
4. Respirator Wearer [SCBA User Paniro Field Staff]
5. Others (then specify) .

The employee will hand over to you following forms:


Fitness for Task Health Questionnaire
Completed Task checklist Please review the Task Checklist which has
already been provided to evaluate the potential health risks relevant to his
job and for ascertaining fitness to work.
Following instructions will help you in carrying out subject health assessment.
Element
Instruction
1. Health Questionnaire
Please complete and sign
off parts 4,5,6,7,& 8.

Rev 2. Apr 2012

Fitness for Task Health Assessment Letter (Field Technical Staff)

Page 1 of 2

FITNESS FOR TASK HEALTH ASSESSMENT


REFERRAL LETTER
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Chest X-ray
Full Blood Count and ESR
Urine D/R
Fasting Blood Sugar
ECG
Blood Group and Type
*Audiometry
** Spirometry
Additional investigations

If clinically indicated
Yes
Yes
Yes
Yes
Yes
Yes
No
If clinically indicated

Audiometry is not required for Karachi or Field Based Office Staff &
Professional drivers unless specifically mentioned.
Audiometry is only required for Field Based Technical Staff:
Field based Production Operators/Technicians/Trainees.
Fire Fighters/Night & Shift workers/Working at Height or
Depth/Confined space worker, SCBA users.
Maintenance: Field Supervisors & Technicians / Field Inspectors.
Construction: Field Supervisors & Technicians.
Petroleum & Drilling: Supervisors/Engineers/
Operators/ Technicians.
REUIREMENTS FOR AUDIOMETRIC TESTS: BESIDES ROUTINELY
TESTED FREQUENCIES & PARAMETERS HEARING TESTS SHALL
ALSO BE DONE AT 3-KHZ.
Requirement for *Audiometry for any job category will be decided by UEP
Health Team
** Spirometry will be carried out only for Respirator Wearers [SCBA Users]
e.g. those working at H2S Facility [Paniro Facility] & will be specifically
mentioned.
Please send all reports including completed health questionnaire and investigation results
in an envelope marked CONFIDENTIAL to Dr. Ahmar Jamal, Sr. HSE Advisor Occupational Health [Cell no. +92-302-8274333] at United Energy Pakistan, Karachi
Office.
Thanks for your help in providing this service.
Kind regards,
____________________________
Name & Signature
Sr. HSE Advisor-Occupational Health / Designate (Field Doctor)/
HR Representative

Rev 2. Apr 2012

Fitness for Task Health Assessment Letter (Field Technical Staff)

Page 2 of 2