Africa Nigeria

8/11/2019 Africa Nigeria

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Revised 6/12

Instructions to the Assignee

YOUR NAME MUST BE WRITTEN ON EACH PAGE OF THIS PACKET.

INCOMPLETE SUBMMISIONS WILL NOT BE REVIEWED.

IMPORTANT: You must receive medical clearance from Halliburton before you are authorized to begin

your international assignment. You will not be deployed to the Assignment Location or be eligible for anyassignment-related benefits, premiums or provisions until this clearance is obtained and reported to HR.

Please follow the steps outlined below immediately to avoid unnecessary delays.

The attached forms must be fully completed by both you and the examining physician/examiner, as applicable.

All documentation must be written in English or be accompanied by an English translation.

1.

MEDICAL PACKET HR STATEMENT- The Human Resource Representative should complete

and this form may be used as the fax/email cover sheet when forwarding the Protocol results.

2.

PRE-DEPARTURE EXAMINATION FORM (COUNTRY SPECIFIC) – Describes the required

medical tests for your country of assignment. All required tests must be performed by the examining

physician and the results forwarded for evaluation.

3. PHYSICAL EXAMINATION RECORD – The examining physician must complete this three (3)

page document complete with signature.

4. MEDICAL QUESTIONNAIRE – Complete this three (3) page questionnaire prior to undergoing the

physical examination. Make this available to the examining physician. Be sure to return completed

questionnaire with this packet. Your name MUST be written on each page of the PhysicalExamination Record as well as Medical Questionnaire.

5. IMMUNIZATION REQUIREMENTS- Complete this form and acknowledge consent. The

examining physician MUST sign the form indicating you have had the required vaccinations or you

will be required to provide a copy of your vaccination records. Each vaccination should have a date of

last receipt or a statement by the physician.

6. MALARIA CHEMOPROPHYLAXIS COMPLIANCE REQUIREMENTS- Please read, signand return this form if included with your protocol.

7.

MEDICAL AUTHORIZATION RELEASE FORM – Please read, sign and return this form.

The completed packet should be sent by fax to: +1-240-813-2774, or send scanned copies of the packet

including the HR Statement Form via email to: [email protected]. This should come DIRECTLY from

the physician’s office.

The company reviews and makes the final determination regarding your medical clearance for internationalassignments. Notification of determination is provided to the Human Resources Department.

Contact your HR Representative for updates on your medical clearance.

mailto:[email protected]





Revised 06/12

Human Resources Employment Statement

The following information is mandatory and required for medical clearance process.

It is to be completed in it’s ENTIRETY by Human Resources and submitted

along with the protocol results.

Pre-Deployment (New Hire) Pre-Deployment (Employee) 2 Year Periodic Transfer

Assignee’s Name ( first middle last )

Date of Birth (mm/dd/yyyy)

Assignee’s Employee Number

Country Assignment: Type: ISTA EXPAT COMMUTER

Home Country (Choose One):

Australia Brunei Canada Malaysia New Zealand

Norway PRL Singapore U.K. U.S.

Cost Center _______________________________________ Company Code ____________________

HR Contact Name: ________________________________________________ _________ ___

HR Contact phone #: __________________________________________________________

HR Contact email address:_____________________________________________________

Please fill out the following information, if available:

Physician Name

Physician Address

Physician Phone #:_____________________ Physician Fax #:_________________________

Return completed protocol to:

Fax: 1-240-813-2774 or

Email: [email protected]







Revised 06/09

Pre-Departure Examination

Nigeria

All tests, along with a physical exam, indicated below MUST

Incomplete examinations will not be accepted and may delay assignment.

be performed.

Name: Date:

Employee/ID Number: Date of Birth:

Country Assignment: NIGERIA Position: Commuter Expat

Urinalysis: Normal Abnormal Blood work*: Normal Abnormal

Audio: Normal Abnormal Spirometry: Normal Abnormal

EKG**: Normal Abnormal Chest X-Ray***: Normal Abnormal *CBC, Retic, Blood Chemistry+ **Only when individual is over 55 years of age or otherwise indicated by exam

***PA/LA if indicated by exam

+Sodium, GGTP, Potassium, Alkaline, Phos, Chlorine, Biliburbin, Carbon Dioxide, Calcium Glucose, Phosphorus, BUN, Uric Acid,

Creatinine, Total Protein, BUN/Creat Ration, Albumin, CPK, Globulin, LDH A/G Ration, SGOT (AST)SGPT ( ALT), Cholesterol andTriglycerides

Additional Comments/Recommendations:

Respirator Approval

Approval to use any appropriate respirator, but not SCBA

Approval to use any appropriate respirator, including SCBA

No respirator approval until cleared by corporate Medical Director

Physical Examination

No medical conditions that preclude remote assignment based upon work assignment information

provided and scope of health testing criteria.

I find this person unfit for duty in this remote location.

Cannot be medically cleared at this time. Recommendations for further evaluation are listed below.

I have advised the employee to follow up with his/her personal physician for the followingmedical conditions:

Physician’s Signature: Date:



Revised 12/11 Page 1 of 3

PHYSICAL EXAMINATION RECORD (To be filled out by examining physician)

PRE-DEPARTURE 2 YEAR PERIODIC EXAM DEPENDENTS

NAME ( LAST, FIRST, MIDDLE ) EMPLOYEE/ID NUMBER DATE OF BIRTH (MM/DD/YYYY)

JOB TITLE ASSIGNMENT LOCATION AGE SEX

VITALS VISION

HT ►

UNCORRECTED CORRECTED

PERRIPHERAL VISUAL FIELD

R_________ L_________WT►

TEMP► Far Near Far Near DEPTH PERCEPTION

B/P► B 20/ B 20/ B 20/ B 20/

Pulse► /Min R 20/ R 20/ R 20/ R 20/ COLOR VISION

Resp► /Min L 20/ L 20/ L 20/ L 20/ WNL ABN

URINALYSIS Protein► Blood► Glucose►

PHYSICAL EXAMINATION►FOR ABNORMAL FINDINGS, √ BOX, MARK (L) OR (R) AND EXPLAIN BELOW

DESCRIPTION

NORMAL ABN COMMENTS

APPEARANCEBody Build (Note obesity, etc.)

Skin (Note scars, location, size)

EYESPupils (Note ERLA)

Fundi

EARS

Canals

T.M.'s

Gross Hearing

NOSE Sinuses

MOUTH

Throat

Teeth

Gum

ENDOCRINELymph Glands

Thyroid

CARDIOVASCULAR Heart sounds, rhythm, murmur

CHEST Lung sounds

ABDOMEN

Inspection

Abdominal Masses

Hernia/type

GENITAL (MALES) Genitalia

RECTAL Prostate/Hemorrhoids

MUSCULOSKELETAL

LEG VEINS Varicose (Note severity)

BREAST

NEUROLOGICALCoordination

Motor Function




Please comment on any significant positive or pertinent negative findings. Include any

opinions as to what, if any, limitations regarding the performance of the functions of

his/her position that should be placed on the examinee or any reasonable modifications of

the workplace that need to be made to accommodate the examinee. If this is predeployment, do NOT comment specifically on whether the examinee is medicallyqualified to be hired.

No further evaluation:

Needs further evaluation:

Additional Comments:

Has examinee been counseled regarding findings and recommendations? Yes No

Will this examinee’s rating change in the next six months? Yes No

PLEASE PRINT

Examining Physician Name:

License Number:

Address:

Telephone Number: Fax Number:





MEDICAL DECLARATION FORM

*PHYSICIAN: Must complete and sign form for validation of fitness for duty*

Last Name First Name Employee/ID Number

Job Title Assignment Location

MEDICAL RATING

(Please circle)

P – Provisional Review required:________________________

A – Fit for all types of work

B – Fit for Office work/light duties

C – Unfit for duty

Will this individual’s rating change in the next 6 months?

If yes, provide details.

Conclusion: I CERTIFY THAT ________________________________________ IS:

(Please check)

1. FIT FOR WORKING IN REGIONS WITH LIMITED MEDICALRESOURCES

2. NOT FIT FOR WORKING IN REGIONS WITH LIMITED MEDICAL

RESOURCES

3. QUALIFIED WITH RESTRICTIONS ___________________________________

_______________________________________________________________

Date of Medical Exam: ________________________

Examining Physician Signature: __________________________________________

Signature Date: ______________________________




Employee Questionnaire Form

Name ( first middle last ): Assignment Location:

Employee Type (circle one): New Hire Transfer Rehire Employee ID:

Company (circle one): HES PRL HAPL HWL HML Other: _________________________

Home Address: Age: Sex: M F

City: State/Province: Zip/Postal Code: Date of Birth (mm/dd/yyyy): / /

Country: HR Contact:

Contact Email: Contact Phone Number:

In the past 12 months have you had any surgery, medical care by a doctor or any change in your health? This includes

dental, vision, hearing, prescription changes, etc. □ Yes □ No If yes, please explain:________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Have you ever been demobilized for medical reasons?□ Yes □ No Condition: __________________________________

MEDICAL HISTORY: YES NO YES NO YES NO

Cancer Stroke Mental Illness

Diabetes (indicate type I or II) Epilepsy/Seizures Drug/Alcohol Abuse

Hepatitis (liver disease) Kidney Disease High Blood Pressure

Allergies Coughing up phlegm Pneumonia

Asthma Frequent colds Severe sore throat

Broken ribs Hay fever Shortness of breath

Bronchitis Spitting up blood Chronic cough

Sleep Apnea Wheezing Night Sweats

Are you currently using a CPAP

or any other breathing device? Type:

Anemia (low blood) Blood Transfusion Leukemia

Bruising (easier than normal) Bleeding gums Sickle Cell Disease

Difficulty in stopping bleeding Other blood issues type: ____________________________________

Numbness in arms/hands/legs/feet Muscle weakness/paralysis Anxiety/Nervousness

Head injury/unconsciousness Epilepsy/Seizures/Convulsions Frequent headaches

Other psychological disorders Depression Frequent dizziness

Stomach pain Stomach ulcer Chronic indigestion

Change in bowel habits Vomiting/nausea Rupture of hernia

Excessive gas/bloating Black stools Blood in stools

Unexplained weight loss/gain Hernia surgery Prostate problems

Kidney/bladder infections Blood in urine Pain with urination

Difficulty starting urination Gallbladder surgery Hepatitis A B C

Cirrhosis Yellow Jaundice Other liver problems

Alcohol consumption Daily oz. Occasional oz. Beer Wine Liquor

If you indicated yes above, please use space to explain & include dates:




YES NO YES NO YES NO

Heart attack/heart disease Heart/chest surgery Chest pains

High blood pressure Irregular or rapid heartbeat Stroke

Enlarged heart Abnormal EKG Heart murmur

Swelling of ankles Deep vein thrombosis Varicose veins

Arthritis/gout/rheumatism Back injury Back pain

Back surgery Joint swelling Knee problems

Neck pain/whiplash Skin cracking/bleeding Skin itching/peeling

Skin discolorations Skin rashes Skin allergies

Mole/growth on skin Psoriasis/eczema Seen a skin doctor?

Hearing difficulties Ear surgery Ears ringing

Ear drainage Dizziness Ear aches

Wear glasses/contacts (explain) For reading? For distance?

Abnormal night vision Blurred vision Cataracts

Burning/tearing/redness of eye Eye allergies or infections Eye surgery

Difficulty with depth perception Glaucoma Color blindness

Allergy to certain foods Allergy to certain medications Other allergies

Smoke Cigarettes Number a day Number of years

Smoke Cigars/Pipe Number a day Number of years

Ex-Smoker Number a day Number of years


HAVE YOU BEEN SUBJECT TO THE FOLLOWING? :

YES NO YES NO YES NO

Noise Exposure Chemical or lead Exposure Radiation Exposure

Asbestos Exposure Other Exposures: ________________________________________

Severe blow to the head Eardrum puncture Skull fracture

Flying or skydiving accident Explosion or blast Knocked out

Driving/auto accident Other trauma: ___________________________________________


CURRENT SYMPTOMS Within the past 24 hours have you:YES NO YES NO YES NO

Experienced ringing in your ears Taken ANY medication Had a toothache

Had a cold, fluid or sinus condition Been exposed to loud noise without hearing protection


FEMALES ONLY: Is there any possibility that you may be pregnant? □ Yes □ No

Date of last menstrual cycle ______/______/______




1. Have you developed any medical condition with your occupation? □ Yes □ No If yes, please provide details (i.e. hearing

loss/skin condition/wheezing/backache/muscle strain/blood disease) ________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

2. Have you ever been denied employment based upon medical grounds? □ Yes □ No

If yes, please explain _________________________________________________________________________ _____________________________________________________________________________________

_____________________________________________________________________________________

3. Do you consider yourself to be healthy? □ Yes □ No

If no, please explain _________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

4. What medications do you regularly take? ____________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________5. List any hospitalization, major illnesses, injuries, surgeries or other conditions (physical or psychological) that you

have EVER had along with the date: _ _____________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Continued explanations to ANY question(s) from above: _______ ______________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

I certify that the foregoing statements are true to the best of my knowledge. I understand that leaving out or misrepresenting the facts calledfor in this questionnaire may be the cause for refusal of employment or termination from the company. I hereby authorize the company toinvestigate the facts claimed by me on this questionnaire.

I hereby grant permission to the examining medical personnel and/or physician to disclose any information herein and hereinafter furnished by me, to authorized company personnel for purposes related to my employment at Halliburton and Associated Companies and to legal

entities requiring such information.

I understand that the pre-placement physical examination given to me is only intended to obtain information for employment purposes ofHalliburton and Associated Companies. It is not a physical examination of the type given by a physician to assess the state of my health andit may not be relied upon by me for that purpose. I must look to my personal physician for such an assessment.

I understand that the medical surveillance test given to me is intended to identify specific instances of illness or health trends suggesting anadverse effect of workplace exposures.

I understand that the examining physician / medical staff and the Halliburton Medical and Disability Department will disclose, in writing, tome and appropriate Halliburton safety and health personnel any findings which, in the physician’s opinion, indicate any adverse effect ofoccupational exposure or pre-existing physical condition which precludes exposure to specific toxic materials or physical hazards.

____________________________________________________________ _______________________

Signature Date (mm/dd/yyyy)



Reviewed 10/11

Immunization Requirements

Due to the global nature of the environment in which Halliburton and its employees operate,

Halliburton REQUIRES all employees traveling/working internationally to be current

on the immunizations required for their specific country location.

Name: Date of Birth:

Employee Number: Country Assignment: NIGERIA Blood Type:

Please indicate for each immunization listed below:

• the most recent date of vaccination;OR

•

a statement regarding acquired immunity (disease/childhood vaccine).

Immunization Dosage ScheduleVaccine administered date/

Statement of Acquired Immunity

Routine: Seasonal Influenza Annually one dose.

Routine: Polio Series completed.*

Routine: Tetanus/Diphtheria (Td) Every 10 years.

Routine: Measles/Mumps/Rubella (MMR) Initial 1 to 2 doses.*

Hepatitis A Two doses lifetime.

Hepatitis B Three doses lifetime.

VaricellaTwo doses or acquired

immunity (previous illness).

PneumococcalOver age 65; then every 5

Years.

TyphoidOral every 5 years;

Injection every 2-3 years.

Meningococcal Meningitis Under age 55 every 5 years;Over age 55 every 10 years.

Yellow Fever** Every 10 years.

* Depending on the country assignment a booster may be required additionally. Please talk with the examining physician.

** Required for travelers arriving from the following countries: Angola, Argentina, Benin, Bolivia, Brazil, Burkina Faso, Burundi, Cameroon, Central African

Rep., Chad, Colombia, Cote d’Ivoire, Congo, Ecuador, Equatorial Guinea, Ethiopia, French Guiana, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Guyana,

Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Panama, Paraguay, Peru, Republic of the Congo, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone,

Somalia, Sudan, Suriname, Tanzania, Togo, Trinidad and Tobago, Uganda, Venezuela

Comments (example: physician Attestation of vaccine unavailability/contraindications/comorbidities):_______________________

______________________________________ ____________________________________________________________ __________________________________________________________________________________________________

List the prescription to be taken for MALARIA prevention (required): ____________________________

I have had the chance to ask questions and they were answered to my satisfaction. I understand the benefits and

risks of the vaccine(s) indicated above, agreed to receive any that are needed, and attest, to my knowledge, the

information is accurate.

Assignee’s Signature: Date:

I attest that the above named person is current on all the required vaccinations indicated above and any additionanecessary vaccinations for the county in with they will be working/traveling.




04/10

Acknowledgement

Malaria Chemoprophylaxis Compliance Requirements

Employee Statement of Understanding and Compliance

Name: Employee ID:

Country Assignment:

I understand that Halliburton, and its associated companies, (“the Company”), are committed to a safe, healthy, and

productive workplace for all employees. We take very seriously the threat of illness or death presented by malaria.The Company has implemented a malaria control program with the stated goal of no cases of malaria among its non-immune populations. I also understand that this program applies to me because I am considered "non-immune” withrespect to malaria at the site(s)/in the location(s) where I am going. I have been provided with information about themalaria control program as it applies where I am going and if I have any questions about this program I understand that

I should seek guidance from a qualified medical professional.

I further understand and agree that:

1. It is a condition of my assignment in/travel to a malarious location that I take an approved malariachemoprophylaxis (medication designed to help prevent me from contracting malaria if bitten by a mosquitocarrying the parasite that causes the disease). The Company has advised me that the malaria chemoprophylaxiscurrently acceptable include Malarone, Doxycycline, Mefloquine (Lariam), or other medication at least as

effective as one of these three, taken according to a prescribed treatment regimen. Saverin (combination ofchloroquin and proguanil) is not as effective in preventing malaria infection as other available alternatives and notan acceptable malaria chemophrophylaxis for work locations in malarial areas.

2. I have been advised to consult a travel medicine professional with questions I may have about the side effects thatmay be inherent in taking malaria chemoprophylaxis.

3. I am subject to unannounced, random and periodic testing to determine my compliance with the requirement that Itake approved malaria chemoprophylaxis as described above and that I am required, as a part of this testing, to

provide, when/where instructed, a urine sample for laboratory verification of my use of an approved malariachemoprophylaxis according to the prescribed treatment regimen.

4. If I refuse to submit to a test or if a medical review of the laboratory analysis of my urine specimen does not

indicate that I am taking an approved malaria chemoprophylaxis, I may be declared unfit for work in a malariouslocation and may be removed from my assignment and/or terminated by the Company.

5. Any problems or disputes arising from or in any way related to this Acknowledgement will be resolved exclusivelythrough the Halliburton Dispute Resolution Program which contains binding arbitration as its last step.

Type of Chemoprophylaxis Used (circle one):

Malarone Doxycycline Mefloquirne (Lariam) Other:___________




Revised 06/09

MEDICAL AUTHORIZATION RELEASE

I acknowledge that the use of and/or possession of prohibited drugs, including

inhalants, and unauthorized alcoholic beverages is a violation of Company policy.

As a condition of employment and further as a condition of performing services for my

employer in support of existing contracts, I consent to submit to a physical

examination, medical screening, or medical questionnaire(s) as required by my

employer.

I also give my consent for specimens to be collected from me to be submitted of drugand /or alcohol testing and additional medical testing as required.

I agree that my employment shall be conditional pending the subsequent results of any

medical evaluation and substance testing.

Further, I herby consent to the release of any and all test results to my employer for its

use or use by an authorized agent.

I release and agree to hold my employer and all their officers, directors, employees and

agents harmless from any claim or liability which for any reasons the Company isalleged to be legally liable in conjunction with the physical evaluation, or the drugand/or alcohol testing.


Witness Signature: Date:

Witness Name: Relationship:(PLEASE PRINT)

Africa Nigeria

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