Medical Evaluations for Fitness to Work - Sakhalin …...OCCUPATIONAL HEALTH AND HYGIENE STANDARD...

OCCUPATIONAL HEALTH AND HYGIENE STANDARD Mandatory Medical Evaluations for Fitness to Work Specification

UNCLASSIFIED Document 0000-S-90-04-O-0270-00-E Appendix 7, Revision 08 Valid from 01.06.2014 to 31.05.2017

Document History Authorisor: R.Dashkov, Custodian: V.Karpenko Printed copy uncontrolled p1 of 22

Medical Evaluations for Fitness to Work

Purpose

To reduce the Health Risks1, risks of injury or illness by evaluation of the personnel health condition to determine their fitness to work.

To define the procedure for the pre-employment and periodic medical evaluations, and health surveillance l arranged for the Company’s employees, establish the principles for using of mitigation measures to prevent the employees from developing occupational diseases.

To carry out medical examination of shareholder seconded staff on the basis of shareholder evaluation protocols.

Who is this for?

• Directors, Heads of Departments and Line Managers • Employees • Contract Holders and Contractors

What situations are covered?

This document applies to all Sakhalin Energy Assets, Facilities, Projects and Activities, including activities undertaken by any Contractor on behalf of the Company.

Regulations

1. RF Labor Code and local regulations of the Company.

2. Russian Federation Ministry of Health care and Social Development dated 12 April 2011, No. 302n "About the approval of lists harmful and (or) dangerous production factors and works at which performance obligatory preliminary and periodic medical examinations (inspections), and an order of carrying out obligatory preliminary and periodic medical examinations (inspections) of the employees occupied on a hard work and on works with harmful and (or) dangerous working conditions are carried out”

3. Guidelines for determination of fitness for work. (Shell HSSE & Control Framework. October, 2010)

4. Guidance for determination of fitness to on sea shelf work in the oil and gas industry (OGUK - Oil and Gas UK), other international guidelines for conducting medical examinations of employees of oil and gas industry that are approved for use in the industry.

5. Ministry of Health of the Russian Federation, the Order of 06.12.12, No. 1011n "On approval of the procedure of preventive medical examination".

6. RF Ministry of Health, Letter of 29.08.13 No. 14-2/10/2-6432 "Guidelines for arranging health survey and preventive medical examinations of adults."

7. Shell Health - Travel health (Shell company website)

8. Medical clearance guidelines for traveling by air.

1 Italicized terms in this document are included in the Sakhalin Energy HSE Glossary.

http://sww-llsak.sakhalinenergy.ru/glasseic/livelink.exe/fetch/-291233/292340/314218/402156/Occupational_Health_Standard.pdf?nodeid=20836163&vernum=1

http://sww-shs.shell.com/health/

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Requirements

Managers are responsible for pursuance of requirements 1-22 in their companies. Corporate Health Manager is responsible for the pursuance of requirements 1 - 6: 1. Making arrangements for medical examinations (preliminary, periodic, extraordinary), interaction with

an authorized medical institution (AMI), notification of the employees that they have medical restrictions in relation to work;

2. Approval of a licensed health facility for carrying out medical examinations; 3. Making out a logs of employees by name and positions/jobs subject to medical examinations; 4. Tracking of the passing of medical examinations as relates the relevant employees in accordance

with the procedure approved by the Shell and other shareholders; 5. Evaluation of the quality of medical examinations; 6. Employees who generally do not travel through Yuzhno-Sakhalinsk (residing at a distance of 50 km

off Yuzhno-Sakhalinsk) have the right to have the relevant documents for a business trip made out with the purpose of a medical examination. All documents for business trips of the staff, which specify a medical examination as one of the objectives of the trip, shall be approved by the Corporate Health Department.

Employee and labor relations department is Responsible for requirement 7: 7. Timely provision to Corporate Health Department of duly issued personal data of company

employees; Prepare and issue to individual staff members (employee) personal referrals to medical examinations; Change job position of the employee to light duty (for easier work) or suspend drawing up of personal referrals to medical examinations;

Department of labor management, compensation and benefits is Responsible for requirement 8: 8. Company’s employees shall be paid for the time of a medical examination in accordance with the

applicable RF labor law and local regulations of the Company. Line managers are Responsible for requirement 9: 9. Liaise consent with Corporate Health with regards to authorization of the employee for work at the

production facility after any event of hospitalization of any duration or outpatient treatment for more than 30 days, or making a decision on the referral of the employee to the extraordinary medical examination, the purpose of which is to evaluate the employee's fitness to work.

ALG and Transport service is Responsible for requirements 10 - 11:

10. Provide transport to employees from remote sites to the place of medical examinations in Yuzhno-Sakhalinsk and back, meeting at the collection points/venues (train station/airport) to Yuzhno-Sakhalinsk and transportation to the place of medical inspection and from through the territory of Yuzhno-Sakhalinsk to Zima Highland Housing Complex, or to the airport/train station/hotel, including, if possible, regular bus services of the Company. This provision is applicable to all categories of employees working at remote locations.

11. Making arrangements for accommodation in hotels of Yuzhno-Sakhalinsk for the employees who are to pass medical examinations in Yuzhno-Sakhalinsk and who travel through Yuzhno-Sakhalinsk to the shift or from the shift, or for the employees residing in the Sakhalin area or outside Yuzhno-Sakhalinsk*, if necessary. Accommodation is provided upon approval of the Line Manager and Corporate Health Manager.

PrD Compliance Department is Responsible for the performance of requirement 12: 12. Is to hand over lists of bases and gets the Final Reports on medical examinations approved by with

the Federal Service for Supervision of Consumer Rights Protection and Human Welfare (Rospotrebnadzor).





Contract Holders are Responsible for requirement 13: 13. Supervise timeliness and completeness of submission by the contractor of all relevant medical

documents with an opinion on the fitness for work, with a signed consent form for the provision of personal health information to an authorized health employee of the production facility.

*Distance from the permanent residence of the employee (in accordance with the marks in his/her passport) to Yuzhno-Sakhalinsk must be more than 50 kilometers.

FLOWCHART of Medical Fitness to Work controls conducting for employees (candidates)

(the validity of the employee’s (candidate’s) fitness on medical indications

to perform work)

Performance of a certain volume of standard medical

examination

Periodic medical examinations, health survey

Analysis of Labor

Conditions

No medical contraindications

Process of alternative

employment

Person is being employed for performance of the work that requires medical evaluation of his/her fitness to

the work

Unfit for

work

Fit for work

Further examination is required

Detailed medical examination with the

evaluation of fitness for work





Special Requirements – Remote Sites Employees

Scope Permanent employees of production facilities: offshore oil and gas platforms, onshore facilities of oil treatment and gas conditioning, oil and gas service facilities, LNG plant, drivers, employees of the international school, etc.

Reporting Forms

Form E2 – referral to medical examination Form E1 - record on medical examination Form SQ2 - Questionnaire for the staff working with use of respiratory PPE Form for calculating of the risk of cardiovascular diseases Consent Form IS-1 - informed consent to release of information

Nature and conditions of work Depends on functional responsibilities and place of work

Questionnaires

Form Q1 - Health Profile Form SQ2 - Questionnaire for the staff working with use of respiratory PPE Form SQ5 - Questionnaire to determine the level of daytime sleepiness (Epworth scale) - for drivers and crane operators Form - Questionnaire for audiometric testing

Medical examination

• Scope of medical examination shall be determined in accordance with the regulatory requirements depending on the type of work and working conditions (work in the oil and gas industry, work in NERTs/departmental fire-fighting service, water treatment, sanitation and maintenance of water supply systems, work in noisy environment, etc.) • X-ray examination of the chest – at least once in two years • Risk of cardiovascular diseases (CVD risk) is calculated for all employees / candidates for employment with the Company of 35 years and older • Calculation of Body Mass Index (BMI) for persons of all ages

Key factors to determine fitness for work

• Contraindications to do certain types of work are defined by the regulatory requirements. • Risk of cardiovascular diseases (CVD risk) – less than 20% • Evaluation of related chronic diseases, evaluation of the need for monitoring the current chronicle process and its medical treatment • Calculation of Body Mass Index (BMI) – up to 35 • No evidence of active use of alcohol or drugs, or presence of any other mental disorder • Vaccination

Additional examination

• When the indicator of the risk of cardiovascular disease (CVD risk) is 20% and higher – consultation of a cardiologist and bicycle stress test to identify underlying pathology is needed. • With the BMI index of 35 or more, consultation of a cardiologist and bicycle stress test to identify underlying pathology is necessary, then the fitness of the employee to perform duties based on the physical ability data of the employee shall be considered. Employees with the BMI exceeding 35 and considered fit to work for health reasons shall be allowed to offshore facilities in consultation with the chief of the facility provided that safety of such an employee at the facility (survival suit and so on) is ensured.

Frequency • Preliminary medical examination - before employment. • Periodic medical examination - in accordance with the regulatory requirements

Regulatory reference

• Order of the Health Minister as of 12.04.2011 No. 302n • Guidelines for determination of fitness for work (Guidelines of Shell HSSE & Control Framework. October, 2010) • Guidance for determination of fitness to work on shelf-located assets of the oil and gas industry (OGUK - Oil and Gas UK),

Performance indicators

% of the personnel carrying out activities at the Company's production facilities covered by medical examinations and found fit for work.





Special Requirements – Office employees (health survey)

Scope Permanent employees of office facilities: Nogliki base Support Camp, Central Offices located in Yuzhno-Sakhalinsk, Zima Highland Housing Complex, office employees of the LNG plant in Prigorodnoye.

Reporting Forms Form E2–D – referral to medical examination Form E1–D – record on medical examination Form for calculating the risk of cardiovascular diseases Consent Form IS-1 – informed consent to release of confidential information

Nature and conditions of work

Nature and conditions of work in the company's offices are not covered by the order of the RF Ministry of Health No. 302n of 12.04.2011 as no hazards are present.

Questionnaire Form Q1 – Health Profile Questionnaire

Medical examination

Medical examinations at the Company for this category of employees are specified in the following scope: • Anthropometry • Blood pressure • Vision and fields of vision • Chest fluorography • Laboratory examination in a certain scope • Risk of cardiovascular diseases (CVD risk) is calculated for all the Company employees/candidates of 35 years and older • Calculation of Body Mass Index (BMI)


• Risk of cardiovascular diseases (CVD risk) – up to 20% • Calculation of Body Mass Index (BMI) – 35 • Evidence of active use of alcohol or drugs, or presence of any other mental disorder

Additional examination

• When the (CVD risk) is 20% and higher – consultation of a cardiologist and bicycle stress test to identify underlying pathology is needed. • With the BMI index of 35 or more, consultation of a cardiologist and bicycle stress test to identify underlying pathology. • Any other examination according to indications and in coordination with the Corporate Health Department

Frequency • Preliminary to employment. • Then the frequency is determined by the established group of clinical supervision, but not less than once every two years

Regulatory reference

• Ministry of Health of the Russian Federation, the Order of 06.12.12, No. 1011n "On approval of the procedure of preventive medical examination" • RF Ministry of Health, Letter dated 29.08.13, No. 14-2/10/2-6432 “Guidelines on medical examination and preventive medical examinations of the adult population”

Performance indicators % of the personnel carrying out activities in office conditions, covered with medical examination





Special Requirements - Employees who frequently travel by air (Health Survey)

Scope Employees who frequently travel by air

Reporting Forms Consent Form IS – 1 – informed consent to the release of confidential information

Nature and conditions of work

Employee who travels by air: • Three or more times per month is in a flight with the duration of over 4 hours

within the range of the RF • Three or more times during the year is in the long-distance (intercontinental)

flights. • Infrequent flights, but within such geographical areas where there is an

increased risk associated with unfavorable local sanitary-epidemiological situation (risk of contracting an infectious disease, underdeveloped healthcare system, remote areas, etc.)

Hazards can include: • Risks associated with flight, e.g.: jet lag, Deep Vein Thrombosis (DVT). • Exacerbation of existing chronic diseases

Procedure Health survey of this group of employees is an addition to the basic medical examination.

Questionnaire Form SQ3 – Questionnaire for employees who frequently travel by air

Medical examination

Medical examinations in the Company for this category of employees are specified in the scope established at the main place of work: • Risk of cardiovascular diseases (CVD risk) is calculated for all employees/candidates of 35 years and older, • Calculation of Body Mass Index (BMI) for persons of all ages


• Evaluation of the risk of exacerbation of chronic diseases (medical conditions). • Focusing on specific requirements due to the geographical location of the place of work and the nature of the work, e.g.: on the high seas, need for prevention of malaria. • Requirements for vaccination in the place of mission and performance of work. • Availability of kits for travelers, if necessary. • Availability of kits for the prevention/treatment of malaria, if necessary. • Issues related to eventual problems that have developed after a business trip. • Impact of the trip on health. • Risk of cardiovascular diseases (CVD risk) – up to 20% • Calculation of Body Mass Index (BMI) – up to 35. • Evidence of active use of alcohol and drugs, or presence of any other mental disorder.

Additional examination Not always necessary – only if clinically indicated, in determining fitness to work.

Frequency Once in two years.

Regulatory reference • Shell Health - Travel health (Shell Company Website) • Medical clearance guidelines for travelling by air (Medical Guide for air

travelers) Performance indicators

% of frequently flying staff evaluated and found fit for work in the Company during 2 previous years.


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Requirements of the Company - arrangements for medical examinations

14. Candidates who have not passed the pre-employment medical or those having health restrictions based on the medical evaluation shall not be employed. In disputable situations, the final decision regarding the Fitness to Work of the Candidate shall be taken by the Company’s Corporate Health Department.

15. The cost of pre-employment medical examination shall be reimbursed to the Candidate in compliance with Article No. 213 of the Russian Federation Labour Code based on the documents confirming the payment for the relevant medical services.

16. Periodic medicals shall be conducted under the order issued by the Chief Executive Officer (CEO). Frequency shall be determined by the law of the Russian Federation in the relevant field and the requirements of this document. The draft order shall be prepared by Corporate Health Department according to the procedure for the registration of orders related to the principal activities. Lists of personnel for medical examination shall be developed on the basis of the approved staff schedule and organization chart.

17. Referrals to periodic medical examinations shall be made up and certified by the signature of an

official of the Department of Human Resources and the seal of the Company, then they shall be provided to persons in charge who have access to the personal data processing, to the Corporate Health Department according to the register for submitting to a healthcare institution. List of persons in charge shall be specified on an annual basis.

18. The results of a medical examination (health profile information) shall be kept by the employee's

health care facility, whereas copies of the results of the medical examination and copies of reports with a comment on fitness shall be handed over to Corporate Health Department and respective medical facilities at the Company sites. Original opinion (form E2, form E2-D form, Attachment 3-4) shall be kept in the Personnel Action File of the Company employee.

19. Following the signing of the Final Report by the Head of the HSE Department or by his/her deputy,

the Corporate Health Department shall transfer 3 copies of this document to PrD Compliance Department for further submission for signature to the Federal Service for Supervision of Consumer Rights Protection and Human Welfare (Rospotrebnadzor) for the Sakhalin Oblast. After signing, one copy of the Final Report shall be sent to Corporate Health Department, and subsequently kept there.

20. Corporate Health Department shall analyze the data on newly diagnosed diseases and consider the

recommendations of health care provider in respect of preventive measures. Summary report shall be compiled. It also shall submit the data on the employees that have not passed medical examination in a timely manner, to the Personnel Directorate, for issuance of an order on suspension from work the persons that have not passed medical examination.

21. Corporate Health Department shall report on the results of the analysis at the meeting of the

Steering Committee for HSE.

22. Carrying out the medical examinations for the shareholders’ secondees shall be performed in accordance with the Protocol on Determination of Occupational Fitness approved by the shareholder (e.g., Protocols of Medical Examinations of the Shell Company and the Guidelines on Determination of Occupational Fitness).





Attachment 1. List of employees

List of employees for regular or pre-employment health screening, specifying occupational hazards and types of activities as per the reference List of Hazards and List of (Hazardous) Activities

"APPROVED"

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Attachment 2. The list of works at which performance preliminary and periodic

medical examinations (inspections) of employees are obligatory required.

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Attachment 3. Form E2: Medical Examination Referral

Employee data

Date of referral (dd/mm/yyyy)

Last name

Given Name_____________________________ Patronymic name

Employee No. Date of birth (dd/mm/yyyy)

Position title

To be submitted to the MPTF (name and address of the institution):

Type of medical examination: pre-employment / periodic medical Detrimental factors/works (as per the Russian Federation Minzdravsotsrazvitiya Order No. 302n dated 12 April 2011) 1. 2. 3.

HR BST Employee Name Position title

(Signature)

Conclusion of the Medical Board The above mentioned person has undergone examination in accordance with the requirements set forth in the specification "Medical Evaluation for Fitness to Work". Currently, the work suitability status of the person corresponds to the one shown below.

Fit, without restrictions

Fit, with the following restrictions

Other (specify) These restrictions are permanent These restrictions are temporary and valid until (date)

Temporarily unfit until (date)

Absolutely unfit

Date Signature Full name seal of MPTF





Attachment 4. Form E2-D: Referral to medical examination Opinion based on health survey results

Employee data Family name: ________________________________________

Given name: _______________________________ Patronymic: _____________________________

Date of birth: _______________________

Department: ___________________________

Position: _______________________________________

Must visit healthcare institution (name and address of institution): Type of medical examination:

Employee has passed the HEALTH SURVEY CHECKUP in accordance with the recommendations of the Department of Occupational Health and Hygiene of the

Company

Date Signature Full name Seal of healthcare institution

Comments from the Department of Occupational Health and Hygiene:

Visits to remote production facilities of the Company are allowed / not allowed Validity of the opinion: 2 years / 1 year / 6 months

(depending on health group)

Date______________ Employee’s full name __________________ Signature_____________ OHH Department





Attachment 5. Form Q1 Health Status Questionnaire Please answer the questions by ticking ( √ ) the correct box. If you are not sure, leave the question blank and ask your examining physician what it means. Your examining Physician may ask you additional questions during the examination.

Employee Data

Date

Last Name First Name

I.D No. Tel # Occupation

No Yes

1. Are you currently being treated by a doctor for any illness or injury? If yes please briefly describe

2. Are you receiving any medical treatment or taking any medication (either prescribed or otherwise)? If yes please list

3. Have you ever had, or been told by a doctor that you had any of the following?

No Yes

3.1 High blood pressure 3.2 Heart disease 3.3 Chest pain, angina 3.4 Any condition requiring heart surgery 3.5 Palpitations/irregular heartbeat 3.6 Abnormal shortness of breath 3.7 Head injury, spinal injury 3.8 Seizures, fits, convulsions, epilepsy 3.9 Blackouts, fainting 3.10 Stroke 3.11 Dizziness, vertigo, problems with balance 3.12 Double vision, difficulty seeing 3.13 Color blindness 3.14 Kidney disease 3.15 Diabetes 3.16 Neck, back or limb disorders 3.17 Hearing loss or deafness or had an ear operation or use a hearing aid 3.18 Do you have difficulty hearing people on the telephone (including use of hearing aid if worn)?

3.19 Have you ever had, or been told by a doctor that you had a psychiatric illness, or nervous disorder?

3.20 Have you ever had any other serious injury, illness, operation, or been in hospital for any reason? If Yes, please give details:





Form Q1 Continued No Yes

4.1 Have you ever had, or been told by a doctor that you had a sleep disorder, sleep apnoea, or narcolepsy?

4.2 Has anyone noticed that your breathing stops or is disrupted by episodes of choking during your sleep?

5.1 When was the last time you had more than 4 drinks (female) or 5 drinks (male) in 1 day in the past 3 months*

last 7 days last 4 weeks last 3 months not in the last 3 months

5.2 Has a relative or friend or a doctor or other health employee been concerned about your drinking or suggested you cut down?

No Yes, but not in the last year Yes, during the last year No Yes

6.1 Do you use illicit drugs?

6.2 Have you ever been treated for alcohol or substance abuse

6.3 Whether you smoke? If yes, specify how many cigarettes per day and how long

7. Do you use any drugs or medications not prescribed for you by a doctor?

If yes list here.

8. Have you been in a vehicle crash since your last license examination? ( Drivers only) If Yes, please give details:

Declaration: I, (Print Name) certify that to the best of my knowledge the above information supplied by me is true and correct. Signature: Date:

Office use only

* The portion (unit) of alcohol is meant as an equivalent of 10ml 96 % of ethanol to an equal 1 glass (250ml) not fortified beer, to a glass of dry wine (100ml), to a glass of fortified wine (60 ml), a wine-glass (30 ml) strong alcohol.

Examining Physician’s comments

Date Signature Print Name





Attachment 6. Form E1. Medical Examination Record *NB Examining Physician – only complete examinations and investigations required by protocol, or those that are clinically indicated from patient history.

Name Job Type Date

Date of birth I.D No Blood Group

Blood Pressure: (mm Hg)

Pulse: (bpm)

Height (m):

Weight (Kg): BMI:

Systems Revision Normal / Abnormal Comment

Head, Eyes, Ears, Mouth, Teeth, Throat

Spine

Breasts

Chest – Respiratory System

Heart - Cardiovascular

Extremities

Musculo-skeletal

Genito-urinary

Rectum-Anus

Abdomen

Neurological System

Skin

Others- incl. Immunization status

Lab Tests*

Vision tests*

Audiogram *

Spirometry *

ECG*

Chest fluorography*

Other* (CVD risk - Cardio risk %)

PLEASE ATTACH COPIES OF IMPORTANT SPECIALIST REPORTS AND LAB RESULTS (Cardio risk to be calculated for the age group of 35 years and older) Examining Physician – additional comments may be recorded on reverse of E1 form






Continued of Form E1 Medical Examination Record Examining Physician - additional comments / doctor’s recommendations


*- this information may be sent to the Department of Healthcare only by written request of the employee (Form IS-1, Attachment 12)





Form E1 – D. Record of medical examination *NB Examining Physician – only complete examinations and investigations required by protocol, or those that are clinically indicated from patient history.

Name Job Type Date

Date of birth

Blood group

Blood Pressure:

Pulse: Height (m): Weight (Kg): BMI:

Systems Revision Normal / Abnormal Comment

Head, Eyes, Ears, Mouth, Teeth, Throat

Spine

Breasts

Chest – Respiratory System

Heart - Cardiovascular

Extremities

Musculo-skeletal

Genito-urinary

Rectum-Anus

Abdomen

Neurological System

Skin

Others- incl. Immunization status

Lab Tests*

Vision tests*

ECG*

Chest fluorography*

Other* (Cardio risk %)

* PLEASE ATTACH COPIES OF IMPORTANT SPECIALIST REPORTS AND LAB RESULTS (Cardio risk is calculated for the age group of 30 years and older)

Attention of specialist doctors - Additional comments may be written on the reverse side of form E1





Continued Form E1 – D. Medical Examination Record

Date Signature Full name

* - this information may be sent to the Department of Healthcare only by written request of the employee (Form IS-1, Attachment 12)

Health Group (encircle)

First

Second

Third

Opinion and recommendations of a doctor *





Attachment 7. Form SQ2. Breathing Apparatus Screening (for NERT members only)

Employee Data Date

Last Name First Name Date of birth Tel # Occupation This form is required to be completed either at the time of your fit testing for respirator use or medical evaluation. If you have never completed an initial questionnaire form, you should not be fit tested nor use a respirator until the initial questionnaire has been reviewed and approved by a health care professional. All information provided on this form and during consultations remains strictly confidential.

1. Have you experienced any health problems/signs or symptoms that you associate with respirator use or the ability to use a respirator while performing your work that requires the use of a respirator?

Yes No

2. Has there been any change in workplace conditions (e.g., physical work effort, protective clothing, temperature)

that has or may result in a substantial increase in the physiological burden placed on you when performing your work that requires respirator use?

Yes No

3. Do you currently have any medical restrictions or limitations (for example: lifting restrictions) that may affect

your ability to safely wear a respirator?

Yes No Not sure

4. Do you have any medical problems (for example: issues related to the heart, breathing problems, seizures, back problems, neck problems, medications, etc.) that may affect your ability to safely wear a respirator?

Yes No Not sure

5. Do you have any medical problems that prevent you or may prevent you from working in a confined space?

Yes No Not sure

6. Would you like to talk with a health professional regarding your health and respirator use?

Yes No

This form must be submitted to a healthcare institution that will evaluate your fitness for use of a respirator in your work. If you answered "Yes" or "Do not know" to any question, then permission to work using a respirator will be issued to you only after the evaluation by a professional medical specialist of the healthcare institution of your fitness to work using a respirator Declaration : I, (Print Name) certify that to the best of my knowledge the above information supplied by me is true and correct. Signature: Date______________________________





Attachment 8. Form SQ3

Questionnaire for employees who frequently travel by air

Data of employee Date

Family name Given name

Phone Position

This questionnaire will help determine if you have any medical conditions that may require a detailed medical evaluation in determining your fitness for work. If you have any medical condition and you believe that a business trip can significantly affect your health, please contact a representative from the Department of Occupational Health and Hygiene of the Sakhalin Energy. You can arrange your trip in full compliance with all relevant safety requirements. All information provided by you in this questionnaire and the consultation process will remain strictly confidential.

Do you feel physically and psychologically prepared for the trip? Yes / No

Do you have a history of deep vein thrombosis (DVT), pulmonary embolism or tendency to form blood clots? Yes / No Are you pregnant? Yes / No Have you had in the last three months hospitalization or surgery? Yes / No Do you have any chronic illness or injury, for example: cardiovascular disease, diabetes or a psychological disorder? Yes / No Are you having now any medical treatment? Yes / No Please specify the disease or condition.

What prescribed medications do you take on a regular basis? This form will be sent out to a facility servicing the Company. If you answered 'Yes' to any of the questions proposed to you, then you should contact the Department of Occupational Health and Hygiene of the Sakhalin Energy for medical advice in relation to your fitness for business trips (by air). Disclaimer: I, (Full name) certify that the information provided by me in this questionnaire is true and accurate. Signature: Date:





Attachment 9. Form SQ5.

Epworth questionnaire to evaluate the degree of daytime sleepiness


Family name Given name

Patronymic

Phone Position

Epworth Sleepiness Scale (ESS) is a questionnaire designed to evaluate the degree of daytime sleepiness.

This questionnaire will help determine whether you have a variety of health conditions that need further attention or to use additional methods of examination in determining fitness for work. If you have any questions, you can contact the Department of Occupational Health and Hygiene of the Company. All information provided by you in this questionnaire, as well as the information obtained in the consultation is strictly confidential. Please answer the question: What is the likelihood that you slumber in the following situations: 0 Never 1 Small probability 2 Moderate probability 3 High probability ___ Sitting and reading ___ Watching TV ___ Sitting in a public place and not actively participating in the events surrounding the (theater, meeting,

etc.) ___ Sitting in a car as a passenger over an hour of riding without stopping ___ If you take a nap after lunch, in the absence of other duties or obligations ___ Sitting and talking to someone ___ Sitting quietly after a lunch without alcohol intake ___ In a car, when is stops for a few minutes during the trip Total ___ If in the end the total number of points is 15 or more, you should seek advice from the Department of Occupational Health and Hygiene of the Company before you continue to work as a driver of the vehicle or operator of machines and plant in your workplace. Disclaimer: I ____________________ (name) hereby certify that the information provided by me is true and correct. Signature: Date:





Attachment 10. Questionnaire for audiometric examination


Family name Name

Gender Male / Female Date of birth

Phone # Position

Medical Data Exposure not related to work

Have you ever had NO YES

Have you ever been exposed to the following: NO YES

1.1. Epidemic parotitis 2.1. Loud music

1.2. Measles 2.2. Sounds of a machine-tool at work

1.3. Diabetes mellitus 2.3. Sounds of a working motorcycle

1.4. Running temperature 2.4. Sounds of gunfire

1.5. Meningitis 2.5. Did you serve in the army?

1.6. High blood pressure 2.6. If "yes", in which troops

1.7. Allergic reactions

Impacts associated with the work 1.8. Ear infections

1.9. Damage to the tympanic membrane

3.1. Did you ever have to use hearing protection?

NO YES 1.10. Discharge from the ear

1.11. Ringing in your ears 3.1.1. Earplugs

1.12. Dizziness 3.1.2. Ear protectors

1.13. Head trauma 3.2.3. Other

1.14. Arthritis

NO YES 1.15. Recent diseases of the paranasal sinuses

3.2. Have you ever been exposed to excessive noise past 14 hours

1.16. Confirmed hearing loss

1.17. Confirmed hearing loss in relatives (aged before 50 years)





Attachment 11. Table for calculation of the risk of cardiovascular diseases for

persons aged 35 years and older. A. For men. B. For women.

РЗС_муж-SEIC-2010

.xlsx РЗС_жен-SEIC-2010

.xlsx





Attachment 12. Form IS-1. Informed consent for the release of confidential information

EMPLOYEE’S CONSENT TO RELEASE OF INFORMATION CONTAINED IN

THE MEDICAL DOCUMENTS I

(FULL NAME)

DATE OF BIRTH

EMPLOYER

I HAVE BEEN INFORMED THAT IN ACCORDANCE WITH art. 13, art. 22 of the Federal Law as of 21.11.2011 No. 323-FZ "On the basics of health protection in the Russian Federation" THE INFORMATION CONTAINED IN THE MEDICAL DOCUMENTS OF THE CITIZEN IS OF DOCTOR-PATIENT CONFIDENTIALITY AND MAY BE RELEASED WITHOUT CONSENT OF THE CITIZEN ONLY IN THE CASES SET FORTH IN THE SAID ARTICLES. INFORMATION ABOUT THE FACT OF SEEKING MEDICAL TREATMENT, THE CITIZEN’S STATE OF HEALTH, DIAGNOSIS AND OTHER INFORMATION RECEIVED IN HIS EXAMINATION AND TREATMENT IS OF DOCTOR-PATIENT CONFIDENTIALITY. WITH THE CONSENT OF THE CITIZEN OR HIS LEGAL REPRESENTATIVE IT IS ALLOWED TO RELEASE THE INFORMATION BEING OF DOCTOR-PATIENT CONFIDENTIALITY, TO OTHER CITIZENS, INCLUDING OFFICIALS. I GIVE MY CONSENT TO THE MEDICAL INSTITUTION ________________________________ TO PROVIDE THE INFORMATION CONTAINED IN MY MEDICAL DOCUMENTS TO THE DEPARTMENT OF OCCUPATIONAL HEALTH AND HYGIENE OF THE COMPANY "SAKHALIN ENERGY INVESTMENT COMPANY LTD.":

(IF NECESSARY, SPECIFY THE NAMES AND POSITIONS OF THE EMPLOYEES TO WHOM YOU ENTRUST YOUR HEALTH INFORMATION)

SIGNATURE DATE


Medical Evaluations for Fitness to Work - Sakhalin …...OCCUPATIONAL HEALTH AND HYGIENE STANDARD...

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