The Medical Self Declaration Form is a crucial document in Indonesian business and healthcare contexts, designed to collect and verify individual health information in compliance with Indonesian law. This document is typically required when organizations need to assess an individual's health status for various purposes, such as pre-employment screening, insurance applications, travel clearance, or institutional admission. The form must comply with Indonesian healthcare regulations, including Law No. 36 of 2009 on Health and data protection requirements under Law No. 27 of 2022. It includes comprehensive health information, ranging from current health status to medical history, while ensuring proper data protection and privacy measures are maintained. The document's structure and content can be customized based on specific requirements while maintaining core elements required by Indonesian regulations.
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1. Personal Information: Basic identification details including full name, ID number (NIK), date of birth, gender, and contact information
2. Purpose of Declaration: Statement specifying the purpose for which the medical declaration is being made (e.g., employment, travel, insurance)
3. Current Health Status: Declaration of current general health condition and any present symptoms
4. Medical History: Overview of significant past medical conditions, surgeries, and chronic illnesses
5. Family Medical History: Declaration of relevant hereditary conditions or significant family medical history
6. Current Medications: List of current regular medications and treatments
7. Certification of Truth: Statement certifying that all provided information is true and accurate
8. Consent for Verification: Authorization for relevant parties to verify the declared information
9. Legal Disclaimer: Statement acknowledging legal implications of false declarations
10. Signature and Date: Space for declarant's signature, date, and witness signature if required
1. COVID-19 Status: Additional section for COVID-19 vaccination status and history - used during pandemic-related requirements
2. Disability Declaration: Section for declaring any disabilities or special needs - used when relevant for accommodation or assistance purposes
3. Pregnancy Status: Declaration of pregnancy status - used when relevant for medical or occupational safety purposes
4. Insurance Information: Details of health insurance coverage - used when declaration is for insurance or healthcare provider purposes
5. Emergency Contact: Emergency contact information - used when declaration is for ongoing medical care or institutional purposes
6. Lifestyle Factors: Declaration of relevant lifestyle factors (smoking, alcohol, etc.) - used when required for comprehensive health assessment
1. Medical Test Results: Attachments of recent relevant medical test results or reports
2. Vaccination Records: Copies of vaccination certificates or immunization records
3. Previous Medical Certificates: Copies of relevant previous medical certificates or doctor's notes
4. Identification Documents: Copies of required identification documents for verification purposes
5. Insurance Cards: Copies of health insurance cards or coverage documentation when applicable
Relevant legal definitions
Clauses
Relevant Industries
Healthcare
Insurance
Education
Manufacturing
Construction
Transportation
Hospitality
Aviation
Maritime
Mining
Oil and Gas
Food and Beverage
Pharmaceutical
Corporate Services
Relevant Teams
Human Resources
Health and Safety
Legal and Compliance
Risk Management
Medical Services
Occupational Health
Employee Relations
Recruitment
Insurance Administration
Corporate Administration
Immigration Processing
Relevant Roles
Human Resources Manager
Occupational Health Officer
Medical Officer
Compliance Officer
Risk Manager
Health and Safety Manager
Employee Relations Manager
Recruitment Specialist
Insurance Underwriter
School Administrator
Corporate Medical Director
Workplace Health Coordinator
Immigration Officer
Company Doctor
Legal Compliance Manager
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