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 any
assignment-related benefits, premiums or provisions until this clearanceis 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 Physical
Examination 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, sign
and 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 physicians office.

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

Contact your HR Representative for updates on your medical clearance.

Revised 06/12


Human Resources Employment Statement


The following information is mandatory and required for medical clearance process.
It is to be completed in its ENTIRETY by Human Resources and submitted
along with the protocol results.

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


Assignees Name (first middle last)
Date of Birth (mm/dd/yyyy)
Assignees 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 and
Triglycerides

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 following
medical conditions:



Physicians 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 EXAMINATIONFOR ABNORMAL FINDINGS, BOX, MARK (L) OR (R) AND EXPLAIN BELOW


DESCRIPTION

NORMAL

ABN

COMMENTS
APPEARANCE
Body Build (Note obesity, etc.)

Skin (Note scars, location, size)

EYES
Pupils (Note ERLA)

Fundi

EARS
Canals

T.M.'s

Gross Hearing

NOSE
Sinuses

MOUTH
Throat

Teeth

Gum

ENDOCRINE
Lymph 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


NEUROLOGICAL
Coordination

Motor Function


Revised 12/11 Page 2 of 3




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 medically
qualified to be hired.


No further evaluation:


Needs further evaluation:


Additional Comments:




Has examinee been counseled regarding findings and recommendations? Yes No

Will this examinees rating change in the next six months? Yes No

PLEASE PRINT

Examining Physician Name:

License Number:

Address:





Telephone Number: Fax Number:


Physicians Signature: Date:

Revised 12/11 Page 3 of 3

MEDICAL DECLARATION FORM

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

Last Name

First Name Employee/ID Number

J ob 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 individuals 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 MEDICAL
RESOURCES

2. NOT FIT FOR WORKING IN REGIONS WITH LIMITED MEDICAL
RESOURCES

3. QUALIFIED WITH RESTRICTIONS ___________________________________

_______________________________________________________________

Date of Medical Exam: ________________________

Examining Physician Signature: __________________________________________

Signature Date: ______________________________


Revised 05/10 Page 1 of 3

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 J aundice Other liver problems
Alcohol consumption Daily oz. Occasional oz. Beer Wine Liquor
If you indicated yes above, please use space to explain & include dates:





Revised 05/10 Page 2 of 3


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




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



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


FEMALES ONLY: Is there any possibility that you may be pregnant? Yes No
Date of last menstrual cycle ______/______/______

Revised 05/10 Page 3 of 3

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 called
for in this questionnaire may be the cause for refusal of employment or termination fromthe company. I hereby authorize the company to
investigate 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 of
Halliburton and Associated Companies. It is not a physical examination of the type given by a physician to assess the state of my health and
it 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 an
adverse effect of workplace exposures.

I understand that the examining physician / medical staff and the Halliburton Medical and Disability Department will disclose, in writing, to
me and appropriate Halliburton safety and health personnel any findings which, in the physicians opinion, indicate any adverse effect of
occupational 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 Schedule
Vaccine 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.
Varicella
Two doses or acquired
immunity (previous illness).

Pneumococcal
Over age 65; then every 5
Years.

Typhoid
Oral 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 dIvoire, 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.

Assignees Signature: Date:

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

Physicians Signature: Date:

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 with
respect to malaria at the site(s)/in the location(s) where I am going. I have been provided with information about the
malaria 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 malaria
chemoprophylaxis (medication designed to help prevent me from contracting malaria if bitten by a mosquito
carrying the parasite that causes the disease). The Company has advised me that the malaria chemoprophylaxis
currently 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 of
chloroquin and proguanil) is not as effective in preventing malaria infection as other available alternatives and not
an 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 that
may be inherent in taking malaria chemoprophylaxis.
3. I am subject to unannounced, random and periodic testing to determine my compliance with the requirement that I
take 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 malaria
chemoprophylaxis 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 malarious
location 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 exclusively
through the Halliburton Dispute Resolution Program which contains binding arbitration as its last step.


Type of Chemoprophylaxis Used (circle one):
Malarone Doxycycline Mefloquirne (Lariam) Other:___________


Assignees Signature: Date:

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 drug
and /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 is
alleged to be legally liable in conjunction with the physical evaluation, or the drug
and/or alcohol testing.




Assignees Signature: Date:


Witness Signature: Date:


Witness Name: Relationship:
(PLEASE PRINT)