ASAP

DIAGNOSTIC
CENTER
QUALITY STANDARD SYSTEM
PRE-EMPLOYMENT MEDICAL
EXAMINATION (PEME)
PART 1
THE COMPANY, ITS VISION,
MISSION AND VALUE STATEMENT
 ASAP DIAGNOSTIC CENTER

ASAP DIAGNOSTIC CENTER is located at ______________________ (Annex

i). It is composed of a secondary clinical laboratory, radiology and ultrasound
department, ECG section, dental and medical consultation department, physical
examination department, HIV laboratory and drug testing laboratory designed and
equipped to perform routine and special dental, medical and laboratory procedures by
our well-trained, licensed laboratory and medical staffs under the strict supervision of
our certified pathologist. Such services is more than enough to cater the foregoing pre-
employment medical examinations (PEME) for overseas contract worker.

ASAP DIAGNOSTIC CENTER: VISION

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ASAP DIAGNOSTIC CENTER: MISSION

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VALUE STATEMENT

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PART 2
COMPANY PROFILE
AND STRUCTURE
COMPANY LOGO AND WATERMARKS

COMPANY STRUCTURE

I. ADMINISTRATIVE FUNCTIONS

a. Executive Department
i. CHIEF OPERATING OFFICER
ii. CHIEF HUMAN RESOURCE OFFICER
iii. CHIEF FINANCIAL OFFICER
iv. CHIEF MARKETING OFFICER

b. Supervisory Department
i. LABORATORY MANAGER
ii. CLINIC MANAGER

II. TECHNICAL FUNCTIONS

a. Laboratory Department
i. PATHOLOGIST
ii. CHIEF MEDICAL TECHNOLOGIST
iii. MEDICAL TECHNOLOGIST
iv. LABORATORY AIDES

b. Medical Department
i. HEAD NURSE
ii. STAFF NURSE
iii. MEDICAL/ NURSE AIDES

c. Other Technical Position

i. MEDICAL DOCTORS
ii. DENTAL DOCTORS
iii. LABORATORY AND COMPANY TECHNICIANS AND
CUSTODIANS
ORGANIZATIONAL CHART

ASAP DIAGNOSTIC CNTER

PART 3
COMPANY LOCATION
AND DESIGN
VICINITY MAP

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FLOOR MAP

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PART 4
ADMINISTRATIVE OPERATING
PROCEDURES OF THE
QUALITY STANDARD SYSTEM
QUALITY STANDARD OPERATING PROCEDURES
(QSS, QUALITY STANDARD SYSTEM)
 OF ASAP DIAGNOSTIC CENTER ON
PRE-EMPLOYMENT MEDICAL EXAMINATION

In view of the foregoing operational services offered by ASAP in conducting

Pre-employment Medical Examinations for Overseas Contract Worker, the center
establish a guidelines in the regulations of the services above-mentioned in reference
with the regulation and mandate of the Department of Health.

Applicants for overseas work who are required to undergo PEME catered by
the center as accredited by the Department of Health will have variation in their health
examination packages among receiving countries and moreover as required by their
principal employer and authorized agency (Section 16 of R.A. No. 10022). With a
reasonable range of fees on the aforesaid examinations to enhance the quality of
PEME.

Rest-assured that the center highly observes quality of performances and

integrity in the purchase protocols of materials and reagents used in the conduction of
such laboratory and medical examinations.

OBJECTIVE

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SCOPE OF APPLICATION

This Standard Operating Procedural Manual applies to all medical

practitioners who are involved in conducting PEME and to all applicants who are
undergoing the said medical examinations.

DEFINITION OF TERMS

APPLICANT a person defined (see OFW) of the Definition of Terms

PEME Pre-employment Medical Examination

QSS Quality Standard System; this procedural manual

GENERAL GUIDELINES

This manual must at all times be a reference in conducting PEME among

applicants catered by the center.

CHAPTER 1: Structure and responsibility

ORGANIZATIONAL STRUCTURE
 Administrative responsibility in the center lies with the head of the laboratory,
pathologist and the clinic manager who maintains the orderliness and smooth
conveyance of each and every procedural steps in conducting PEME.

ORGANIZATIONAL FLOW CHART

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PERSONNEL

Every section of the laboratory and the center maintains an adequate number
of qualified, trained and competent staff depending on the workload and the services
being provided to ensure an efficient and effective delivery of our PEME services.

A. Manpower force as required by the Department of Health

Personnel Total Number of
Personnel
STAFF FROM CLINICAL
SERVICES
Head or Medical Director 1
Examining Physician(s) 1
Registered Nurse 1
Psychologist(s) 1
Psychometrician(s) 1
Audiometrician(s) 1
Dentist(s) 1
STAFF FROM ANCILLARY
SERVICES
Pathologist 1
Medical Technologist(s) with a 1
valid HIV Proficiency Certificate
Laboratory Technologist(s) 1
Radiologist 1
X-ray technologist(s) 1
STAFF FROM
ADMINISTRATIVE/SUPPORT
SERVICES:
Administrative Officer (AO) 1
Quality Management 1
Representative (QMR)
OTHER SERVICES:
Custodian 1
Record Clerk 1
 Receptionist/ Laboratory 1
Clerk(s)/ Collecting Officer
See ANNEX???

B. Personnel responsibility
Personnel Responsibilities
STAFF FROM CLINICAL
SERVICES
Head or Medical Director Acts as an adviser
and consultant to
the medical and
laboratory staff as
a whole regarding
the appropriate
diagnostic
protocols and
clinical pathologic
correlation of
results. He is the
over-all
administrator of
the different
sections of the
center.
Examining Physician(s) Duly licensed by
PRC responsible
in conducting
physical and
medical
examinations to
applicants
Registered Nurse Assist the
examining
physician in the
following but not
limited to: taking
the medical
history, weight,
height and vital
signs of the
applicant, taking
the cardiogram
and conducing
pre- and post-
HIV test
counseling.
Psychologist(s) Responsible in
Psychometrician(s) conducting the
psychological
 examinations to
applicants
Audiometrician(s) Responsible in
conducting the
audiometry test
for the applicants
Dentist(s) For dental
clearance.
STAFF FROM ANCILLARY
SERVICES
Pathologist Responsible to
ensure the quality
control programs
of the laboratory
and the policies
and procedures
set forth are
followed.
Medical Technologist(s) with a Responsible for
valid HIV Proficiency Certificate performing HIV
test among
applicants
Laboratory Technologist(s) Responsible to
carry out all
policies and
perform
laboratory
procedure to
provide prompt
and accurate
laboratory results
to clinicians. The
premier staff
under analytical
section.
Radiologist Head of the x-ray
facility
responsible in
conveying the
results of the
applicants chest-
PA
X-ray technologist(s) Responsible in
getting the x-ray
reading
STAFF FROM
ADMINISTRATIVE/SUPPORT
SERVICES
Administrative Officer (AO) Responsible in
managing the
 overall areas of
the center and its
operations.
Conducts regular
staff meetings to
discuss issues,
evaluate existing
center policies,
recommend
proposals to
address issues in
the laboratory
and implement
changes needed.
Quality Management Initiate, support
Representative (QMR) and implement
quality
assessment and
performance
improvement
activities in
accordance with
the quality policy
and objectives of
the center.
OTHER SERVICES:
Custodian(s) Tasks in
maintaining the
cleanliness and
other materials
needed by the
center. Ensures
proper waste
management in
the center.
Record Clerk(s) Maintains the
records of the
applicants
Receptionist/ Laboratory Responsible for
Clerk(s) the initial
assessment of the
applicants, and
also may assist the
laboratory staffs
in preparation
before specimen
collection by
providing the
applicants
instructions/
 procedures.
Assist the
applicants in
signing all
necessary forms
and documents;
assess the total
fees for payment;
function as a
cashier or
collecting officer.
(NOTE:
INSTRUCTION
NOTICE should
always be
attached on
requisition forms,
especially for
specimen
requiring fasting
and/or special
preparation prior
to collection,
ANNEX???)

C. Center Operation
a. The center is open from ??? to ??. Mondays to Saturdays.
b. Personnel are required to report on their designated work-shift, ANNEX
???. Reporting time shall be strictly followed.
c. Specimens are examined on the first-come-first-serve basis.
d. The observed a NO noon break policy ??
e. The observance of snack time shall be adopted on all personnel
concerned. A 15-minutes break for snack in the morning and afternoon
and a 30-minutes lunch break in shifting schedule among personnels.
f. Emergency leaves or absences must follow the corporate policies (Refer
to Human Resource and Employees Manual)

CHAPTER 2: Service delivery flow of the

center
TECHNICAL STANDARS
 To ensure the accuracy, precision and timeliness of all results, technical
standards have been formulated by the center and will be applied to all laboratory
requests, results, and reporting procedures. (Service Delivery Flow, ANNEX ???)

LABORATORY EXAMINATION

A. REQUISITION FOR LABORATORY EXAMINATION, (List of Basic and

Add-on laboratory examination for PEME, ANNEX???)

Each laboratory requests should be written in a prescribed form,

ANNEX??, which is completely filled up with the name of the requesting
party/physician legibly printed and signed.

Pertinent data included in the request form are the following:

1. Applicant’s full name (Family, given and middle name must
all be included)
2. Applicant’s age upon examination
3. Applicants date of birth
4. Applicant’s gender (male or female)
5. Applicant’s image/ photo
6. Applicant’s civil status (single, married, divorced, widow(er)
or legally separated)
7. Applicant’s complete address with zip codes
8. Applicant’s requesting party/physician and his signature
9. Laboratory tests to be done.

NOTES:
i. The completed requisition form should be sent to the laboratory by the
applicant with the corresponding specimen properly packed and labeled
except in the procedures where specimen has to be collected/ extracted
by the Laboratory staffs.
ii. It is essential to follow strict quality control procedures through all
stages of the test requisition to avoid errors and misidentification
iii. All laboratory requests are logged in at the General Laboratory Entry
Book (ANNEX???) by the receptionist-on-duty, and an entry number is
assigned individually on each request form.
iv. Laboratory examinations to be done are to be paid at the laboratory
reception desk and is charged and billed by the receptionist-on-duty.
v. An appropriate dated record of its receipts, disposition and examination
and of the findings obtained shall be made and kept on file following the
stated retention policy of the laboratory (ANNEX????) after receipt or
in accordance with the Bureau of Health Facilities and Sytandars
whichever is more stringent.

B. ACCEPTANCE AND COLLECTION OF SPECIMEN

Acceptance and collection of specimen follows the strict protocol of the

laboratory department. As stated:
 i. No person shall be given any parenteral injection for the collection of a
specimen except by a license physician or other person as authorized or
licensed by Philippine Regulatory Board to perform venipuncture for
specimen collection.
ii. Acceptance of specimens submitted by a representative for examinations
shall follow the strict requisition standard policy of the laboratory before
examination.
iii. All blood collections for Clinical Chemistry, Hematology, and Serology
analyses are done by the Medical Technologist/ Laboratory
Technologist.
iv. Specimen for stool examination should be fresh and placed in clean,
wide-mouthed container.
v. At least 30-50cc of the first morning/ random urine should be submitted
for urinalysis. It should be collected in dry, thoroughly washed specimen
bottle provided by the laboratory. No urine preservation protocol for
routine urinalysis.
vi. All specimen for pregnancy tests should be run with a control at least
every pregnancy test box.

C. REJECTION CRITERIA

The adequacy or inadequacy of a specimen shall be determined by the

laboratory personnel. Our personnel has the sole right to whether accept or
reject samples being submitted. Major factors to consider are the time of
collection, amount of the specimen, or presence of contamination. Request
forms with incomplete data shall not be entertained unless completed.

The following guidelines should be followed:

i. Generally, no specimen shall be examined if unsuitable for testing

because of improper collection, improper preservation, apparent
spoilage, excessive time lapse between collection and examination when
applicable, or other reasons sufficient enough to render the findings of
doubtful validity.
ii. Request forms with incomplete data shall not be entertained.
iii. All hemolyzed samples shall be unacceptable for testing.
iv. In women, it is important that urine specimen is not contaminated with
menstrual flow.
v. Collected samples for stool analysis must be brought to the laboratory
immediately within an hour after collection.
vi. Specimens that do not conform to the quality control standards of the
center shall not be accepted for testing.

D. PROCESSING OF SPECIMENS
a. After request and specimen have been recorded, it should be assigned
with a laboratory number (ANNEX???) and endorsed to the respective
section area for examination.
b. All glasswares to be used in the performance of laboratory examinations
should be properly labeled with the patient’s identification.
 c. The laboratory staff is required to save the specimen following the
retention policy of the laboratory (ANNEX???) not until all
examinations desired have been accounted for.
d. All staff should inform the Pathologist immediately when an unusual
observation is made or any problem encountered in their duty to
perform examination.
e. The laboratory staff shall check all results prior to recording if its
respective logbook, Laboratory report logbooks, ANNEX ??

E. REPEAT TESTING
a. Any abnormal results must be checked and validated prior to release of
the results.
b. Any doubtful results should be referred to the Pathologist for further
evaluation.

F. REPORTING OF RESULTS FOR LABORATORY TESTS

a. The medical technologist is required to enter the test results correctly in
the official result form after the examination is completed.
b. All laboratory reports are done electronically and should be free from
error and alteration, if not, this invalidates the whole laboratory reports.
c. Laboratory test reports without an Entry Number, and Laboratory
Number is invalid.
d. The signature of the medical technologist and the pathologist should
appear in the final result forms.

NOTE: For Laboratory Test Evaluation Report, see ANNEX ???

PHYSICAL EXAMINATIONS

Thorough and complete physical examination is done to the applicant by a

licensed physician assisted by a duly registered nurse.

The following demographic data must be carried-out:

a. Physical appearance
a. Height in centimeter
b. Weight in kilograms
c. Body Mass Index
b. Vital Signs
a. Temperature upon examination
b. Blood Pressure
c. Pulse Rate
d. Respiratory Rate
e. Cardiac Rate
c. Thorough physical examination
a. Over-all stature of the applicants
b. Physical examinations to be conducted by a certified physician.

NOTE: For Physical Test Evaluation Report, see ANNEX??

X-RAY EXAMINATIONS (CHEST-PA)

All applicants for overseas must undergo a chest-PA view. For female
applicants, pregnancy testing must be carried out before the conveyance of chest-PA.
This is done with digital imaging as required by the Department of Health. All
abnormal and significant results must be endorsed to a medical practitioner relevant
a relevant clinical correlations and further evaluation.

NOTE: For X-rayTest Evaluation Report, see ANNEX??

PSYCHOLOGICAL EXAMINATIONS

As required by Department of Health, under Administrative Order No. 2013-

0006, and regulated by Republic Act No. 10029 or the Philippine Psychology act of
2009, all guidelines and implementing rules and regulations therein must be strictly
followed by the center. See ANNEX?? And ANNEX ???

NOTE: For Psychological Test Evaluation Report, see ANNEX??

DENTAL EXAMINATIONS

Dental examination is one of the crucial examinations that needs to be carried

out to applicants overseas and it is conducted by a licensed dentist. Only routine dental
examinations is performed.

NOTE: For Dental Test Evaluation Report, see ANNEX??

AUDIOMETRY TEST

Pure-tone air conduction test is performed among seafarers, however it is also

performed among land-based overseas worker if requested by the employer/ principal
or if it is deemed necessary. It is performed by a trained audimetrician who was trained
and certified from a competent training provider, authority or professional
organization.

NOTE: For Audiometry Test Evaluation Report, see ANNEX??

VISUAL ACQUITY AND COLOR PERCEPTION TESTS

A. Visual Acquity Tests Use of Snellen’s, Jaeger’s Method for testing

B. Color Perception Tests Use of Ishihara 24 plates method for testing

NOTE: For Visual Acquity and Color Perception Test Evaluation Report, see
ANNEX??

ECG

A 12-lead ECG must be performed to all applicants especially those who are 40
years old and above and as requested by the principal/ employer of the duly requesting
physician for further evaluation and assessment.
 NOTE: For ECG Reading and Interpretation Evaluation Report, see
ANNEX??

MEDICAL EXAMINATIONS

All examinations must be conducted by a duly licensed physician who are

trained in performing such examinations.

A. EENT All applicants

B. OB-GYNE For female applicants only.

NOTE: For EENT and OB-GYNE Examination Evaluation Report, see

ANNEX?? And ANNEX??? respectively.

RELEASING OF RESULTS

After all tests and examinations has been carried-out, all results must be gather
at once for the final assessment of the applicants whether fit or unfit to work. Final
Evaluation Report must be done. See ANNEX??

The following general guidelines must be carried-out for the releasing of results:

A. All official reports shall be followed up by the apllicants himself and/or his
requesting physician. Consent form (ANNEX??) is needed from the patient if
he can not follow-up his result personally and should only be given to his
immediate family member.
B. If the result is followed-up by his requesting physician or the performing
physician, no consent is needed from the patient.
C. All results are to be signed-out from the Laboratory Releasing Logbok
(ANNEX??) before they are issued; and from the Spindle Delivery Logbook
(ANNEX??) upon delivery.
D. No laboratory results is to be released without full payment of the examinations
done. Payment of bills must be done to the center’s cashier duly authorized to
collect fees. (see ANNEX??? Fees for PEME, duly posted in conspicuous area
for public information as duly mandated by Administrative Order No. 2008-
0002, ANNEX??? and Department Circular Order 2008-0253, ANNEX???)
E. Request for duplicate shall be granted only to those with valid reason. Request
for duplicate form should be properly filled up, see ANNEX ??

NOTE: SEE ANNEX?? FOR THE LIST OF REQUIRED

LABORATORY AND MEDICAL EXAMINATION IN PEME
FOR OVERSEAS CONTRACT WORKER

CHAPTER 3: Physical plant and facilities

 ASAP DIAGNOSTIC CENTER, in coordination with the Department of
Health in its high regard to an adequate, safe and effective workplace and testing
center, maintains its facilities at all times by means of considering the different areas
of concerns in the workplace to ensure such regulations for the constructions,
renovation, maintenance and repair of our facility.. Evaluation of the physical lay-out
of the center is based on these areas of concerns and in accordance with the planning
guidelines prepared by DOH through BHFS posted at its website www.doh.gov.ph.

The floor plan of the facility is signed and sealed by a licensed architect and/or
engineer (see ANNEX???) and shall contain the different working areas conforming to
the required space as prescribed by DOH. Meanwhile, we also take into the picture the
diffrenet hazards that we consider to eliminate in evaluating our physical lay-out. To
mention:
a. PHYSICAL HAZARDS
Physical-related accidents and occupational illnesses that results
from unsafe physical arrangement and physical plant.
b. BIOHAZARDS
Potentially infectious materials that may result from the
performance of an employee’s duties, see ANNEX??
c. CHEMICAL HAZARDS
Chemically related occupational illnesses and injuries in the
workplace.
d. ERGONOMIC HAZARDS
Cumulative trauma disorders in the workplace involving the
musculoskeletal or nervous systems, or both, in response to long-
term, repetitive twisting, bending, lifting, or assuming stating
posture, see NNEX???

FIVE AREAS OF CONCERNS IN THE WORKPLACE

Evaluation of the physical lay-out design of the center is based on the fice areas of
concerns. These are the following:

1. PATIENS, CLIENTELES, APPLICANTS FOR PEME AND OTHER

PERSONS CONCERN
The initial evaluation focuses for those outside the center. There
must not be any recirculation of laboratory air into any inpatient or
outpatient areas. In particular, we do not have any open testing areas
that might expose immune-compromised patients to aerosols. Access to
phlebotomy areas and restrooms is separated from the technical areas.
Laboratory egress to corridors shared by patients is separated by a door
to maintain airflow separation.
In an effort to protect those outside the testing center, we ensure
that specimens and iother materials use are disinfected, sterilized or
contained in a maner to minimized if not to absolutely eradicate the
hazard of an accident during transportation, e.g.g disposal and
collection by the Municipal Collecting Unit
 Since ASAP DIAGNOSTIC CENTER, do not have its own
autoclave or incinerator, we provide a separate room to store red bags
and yellow bags until collected for removal by a laboratory staff or a
licensed disposal company. Such provision removes hazardous waste
from traffic areas and contains potential spills and odors.

2. PERSONNELS
Staff safety is the second major design-related area on which we
focused. Specifically, documentation of policies that prohibits
smoking in all area, eating, drinking, application of make ups.
Contact lens manipulation and mouth pippeting in all technical work
areas.
The design response to these concerns starts with
eliminating drinking fountains, food and drink refrigerators,m and
mirrors in the technical areas including the specimen collection area,
e.g. urinals. Staff eating areas is completely separated from the
technical areas.
Break room opening will not pass into the testing areas
since carrying of food and drinks through could create
contamination of these items.
Staff safety concerns require emergency eyewash is
provided within or less than 100 feet or 10 seconds of travekl from
every area where hazardous chemicals or biohazards are present.
Within the boundaries of maintaining optimal workflow,
isolating noise producers such as freezzers in adjacent testing areas
is considered for limiting noise levels in the center, especially in areas
that require absolute noise-free or is even sound-proofed for a quality
test result output, e.g.g Audio room for audiometry test.
To prevent musculoskeletal disorders, ergonomic factors
were addressed by designing workstations that allows staff to change
positions. Providing adjustable monitor arms, keyboard trays and
chairs can be quick, easy and relatively inexpensive solutions to
ergonomic issues.
The possibility of lifting was also addressed. Tall storage
are often a better design solutuion than underhead torage options.
Reaching to the tops of tall cabinets is usually easier than pother
alternatives and heavier items may be place at a lower level in the
cabinets.

3. SANITATION
Cleanliness is th third major area or review carrying
design implications. Inspectors from sanitation Agency are
concerned with the general cleanliness and maintenance of work
areas including walls and ceilings, as well as the decontamination
of benches and waiting areas. However technical areas such as
the testing areas and the analytical areas meg.g laboratory and
phlebotomy area, etc, will be maintained by the technical staffs
positioned in that areas (see ANNEX?? for the common
disinfecting agents used).
 From a design perspective, counter and floor materials
that can withstand round-the-clock exposure to water, heat and
chemicals were specified. Surfaces are cleanable, hence fabric
and carpeting in laboratory and testing areas are prohibited.

4. FRESH AIR
Air quality is the fourth design related factor. We determine
whether examination and storage areas are adequately ventilated to
remove noxious fumes and odors. It is also verified that ventilation is
adequate for the workload and procedure types performed in the
laboratory and if vapor concentrations are maintained below the
recommended maxima.

5. SPACE
Space is the final aspect of design-related criteria evaluated. One
of space issues is whether adequate room is available for technical and
clerical work.of course, space must be provided for those functions and
we discourage sharing of testing areas between different requisition
examination to allow ease in the work flow. We have separate space for
specimen preparation and collection, laboratory information and record
section.
Thus we determine that sufficient space has been provided and if
utilities are adequate for collection, gross examination and storage of
specimens. These concerns were ideally met.
The final space concerns relate to safety. These includes a review
of whether sufficient space is available so there is no compromise in the
quality of work or safety of personnel and wheteher adequate space is
p[rovided for accession of potentially biohazardous specimens.
In the case of specimen safety, several design-related issues exist.
Adequate space is available for receiving and triaging specimens as they
arrive in the lab. Above all, before planning for thje movement of
specimens in the lab, we remembered every specimen entering the lab is
an unknown and potentially biohazardous.

HEALTH AND SAFETY DESIGN CONSIDERATIONS IN THE TESTING

CENTER

For all areas in the testing center, we consider health, safety and regulatory
compliance in order to meet our missions and objectives. Safe environment is where
employees and patients are protected from physical, chemical, and biological hazards.
The following are considered:
A. LAYOUT
a. Laboratory space is physically separated from personal desk space,
meeting space and eating areas. Workers do not have to go through
a technical space where hazardous and infections materials are used
in order to exit from non-technical areas. We consider making visible
sep[aration between laboratory and non-laboratory space, for
instance with different flooring.
 b. Door to laboratory is strictly accessible for laboratory staffs only.
Specimen collection are is located outside the analytical areas.
c. Entryways have provisions for mounting emergency information
posters other warning signages immediately outside the laboratory,
e.g. on the door.
d. Laboratory areas with machines ang apoparatuses have adequate
room to allow access and clearance behind it for mainatenace.
e. Storage areas and cabinets are constructed to provide adequate room
for temporary storage of materils before and after processing.
f. Waiting areas are physically separated and conveniently located.
g. To allow for security of laboratory materials, laboratory door is self-
closing.
h. Different waiting area for pediatric patients is also provided.
i. The re is also a provision for breastfeeding area
B. FURNITURE AND FIXTURES
a. Work surfaces are chemical resistant, smooth, and readily cleanable.
b. Work surfaces, including computer areas, is ergonomic-
incorporated features, such as adjustability and equipment layout.
c. Bench work areas have knee space to allow room for chairs near
fixed instruments, equipments of fro procedures requiring prolonged
operations.
d. Hand washing sinks is separately provided for staff and patients and
it is different form the laboratory sink.
e. Soft sofa benches are also provided for senior citizens and pregnant
patients.
C. STORAGE
a. Cabinets for chemical storage were made with solid material and
sturdy conmstruction. Hardwood shelving is used.
b. We also have area for any waste storage needs.
c. Wall shelving has heavy-duty brackets.
d. For office spaces, bookcases are preferred to wall-mounted shelving.
e. Flammable liquid storage cabinets are located in the lowermost
areas.
f. Reagentsin volume are not allowed to be stored in uppermost
drawers.
g. Storage area is provided with an ezhaust for a significant odor or
vapor comtrol.
h. Corrosive lkiquids have ample storage space low to the floor,
preferably in low cabinets.
i. There is an allowable space for the variety of aste collection
containers.
j. We include general wastes, laboratory trash, broken glasses, sharps,
recyclable containers, used oil, medicl waste, expired reagents,
and/or radioactive waste.

D. VENTILATION
a. Operable windows are provided in every areas of the testing center.
b. We consider the need for vented chemical storage areas or cabinets
for chemicals with low odor thresholds.
 c. Semi-conductor dn other hazardous gases are places in vented
cabinets.
d. Storage containes for perchloric reagents are made of stainless stel
materials.
e. Areas for these storages are not accessible from non-personnels.
E. EMERGENCY EQUIPMENTS
a. Eye wash and hand wash area is provided for patients within 100 ft
or 10 seconds travel access.
b. Drench hoses support is provided.
c. Wash areas have plumed drains.
d. Flooring under wash areas is slip-resistant.
e. Fire extinguishers and safety wash areas are conspicuously labaled.
f. Fire extinguishers appropriate for the chemicals and equiptments in
use is placed under the entrance of the testing center.
g. Emergency alarm is also provided.
h. Windowless areas (halfwaw) have emergency lighting.
i. Emergency precautions and warning informations are conspicuously
proidd in all area of the testing center.

F. UTILITIES
a. Utility shut-off controls are located outside the center.
b. The center has an abundant number of electrical supply outlets to
eliminate the need for extension cords and multi-plug adapters.
c. automated voltage regulators is providd for the machines and
apparatuses in use.
d. Electrical panels are placed in an accessible are not likely to be
obstructed.

HAZARD PREVENTION STRATEGIES OF THE CENTER

1. ADMINISTRATIVE OPERATION CONTROLS

a. General consciousness of maintaining a safe work environment
b. Appropriate orientation to safety rules.
c. Continuing education.
d. Safety training on a variety of topics such as electrical safety slips and
falls, back care, computer workstations ergonomics, etc.
e. Safe maintenance prctices.
f. Sfety inspection, investigations of workplace ccidents
g. Annual safety reviews.
h. Regular safety surveys of various workplaces and walkways.
i. Disaster drills and other emergency action planning.
j. First aid.
k. Documentation of instructions on safety procedures.
l. Management’s insistence in providing clear safety guidelines.

2. PHYSICAL HAZARDS CONTROLS

a. Warning signages
b. Fire extinguishers
c. Emergency alarms
 d. Spacious hallways and waiting areas
3. WORK PRACTICE CONTROLS
a. Hand washing before and after each patient contact
b. Cleaning surfaces with disinfectants or decontaminating agents
c. Avoid unnecessary used of needles and sharps and not recapping it
d. PPE (personal protective equipment, see ANNEX??) and barriers
e. Red bag and yellow bag disposal
f. Immunization for hepatitis
g. No eating, drinking or smoking in the testing center
h. Applying cosmetics and contact lenses is prohibited
i. Maintenance of the collection area and all other areas every now and
then, see ANNEX???
j. List of hazardous chemicals: toxic, carcinogenic, suspected carcinogenic.
k. Transport of hazardous chemicals and materials by a licensed Sanitary
Company, see ANNEX????
l. Disposable of hazardous chemicals, refer to waste management plan.
4. ENGINEERING CONTROLS
a. Puncture-resistant containers for disposal and transport of needles and
sharps.
b. Safety needles that automatically retract after removal
c. Biohazards bags
d. Splash guards
e. Volatile liquid carriers
f. Mechanical pipetting device
g. Computer arm pads
h. Faucets

5. ERGONOMIC HAZARDS CONTROLS

a. Job rotation to minimize repetitive tasks
b. Job-site modifications
c. Break-time in between the 8-hours duty to avoid long-term exposure to
mechanical pressures
d. Addition of manpower when productivity limits are set too high
e. Engineering controls such as ergonomically correct seating, table heights
and padded edges.

CHEMICAL HAZARD COMMUNICATION PLAN

1. Written hazard communication program.
2. Maintain inventory of all chemicals with chemical and common name if
appropriate.
3. Manufacturer must assess and supply information about chemical or physical
hazards (flammability, explosive, aerosol, flashpoint, etc.)
4. Employers maintain a Material Data Sheets (MSDS) in English
5. MSDS must list all ingredient of a substance greater than 1% except for known
carcinogens if greater than 0.1%
6. Employers make MSDS available to employees upon request
7. Employers ensures labels are not defaced or rmoved and post appropriate
warnings.
8. Employers provide information and training (right-to-know)
 9. OSHA permissible exposure limit, threshold limit, or other exposure limit value
10. Designation of responsible person(s) for the program

MANPOWER INVOLVED UNDER THIS PROGRAM

A. Administrator
B. Company Custodian
C. Technical Staffs

WASTE MANAGEMENT PLAN

?????

NOTES:
i. All medical waste treated before segregation and disposal should be
recorded on the Infection Control Log Book properly filled up and signed
out by the Laboratory/ Clinic Custodian, see ANNEX??
ii. All general segregated for disposal and collection by the Municipal
Collecting unit should be recorded on the Waste Disposal Log Book
properly filled up and signed out by the Laboratory/ Clinic Custodian, see
ANNEX??

PHYSICAL PLANT OF THE CENTER

ASAP DIAGNOSTIC CENTER, for its foregoing application to the premier

testing center for Pre-employment Medical Examinations for Overseas Contract
Workers maintains an adequate areas to ensure the safety of staff and its clients, also
for the efficacy and effectiveness in carrying out its entailed services.

A. GENERAL ADMINISTRATIVE SERVICE AREAS

a. Office of the Medical Director
b. Reception and registration office (business office) with client’s waiting
area
c. Reporting section or the medical records room
B. CLINICAL SERVICE AREAS
a. Medical/Physical examination rooms
b. Dental clinic
c. Optical room
d. Audiometry room
e. Psychological testing room
f. Pre- and post-test HIV counseling room
g. Consultation room for the following examination:
i. EENT
ii. OBGYNE
C. ANCILLARY SERVICE AREAS
a. Secondary clinical laboratory
i. Phlebotomy area/ specimen collection area
ii. Clinical working area
 iii. Pathologist’s area
iv. Toilet facility
v. Waiting/reception area
b. HIV Laboratory
c. Drug Testing Laboratory
d. Radiology area
i. X-ray room with contraol booth and dressing area
ii. Area for x-ray equipment
iii. Radiologist’s area
iv. Acess to toilet
v. Waiting/reception area
D. SUPPORT SERVICE AREAS
a. Toilet (separate for female and male)
b. Staff pantry or break rom
c. Suuply storage room
d. Waste holding room
e. Janitor’s closet
f. Braest feeding room
E. COMMON UTILITY SERVICE AREA
a. Common hal ways and waiting areas

NOTE: See Floor plan, ANNEX??

CHAPTER 4: Equipment and Instruments

ASAP DIAGNOSTIC CENTER in its mission to provide a quality and
affordable services, the following protocols is highly observed:
1. There is an adequate number of operational equipment to provide the
procedures within the facility, see ANNEX??
2. There is a calibration, preventive maintenance and repair program for
equipment in the facility.
3. There is a contingency plan in case of equipment breakdown and malfunction.

INTERNAL QUALITY CONTROL

A. Maintenance-related to laboratory use of equipment

Properly maintained and well-functioning equipment is essential to the
provision of reliable result output. Since equipment is a vital tool in the
operations of the laboratory. Its proper use, care and storage should be
observed. Thus, a program on the preventive maintenance should be made as
part of the Total Quality Management of th laboratory.
OBJECTIVE:
1. To ensure good quality performance of laboratory
equipment, thus reducing conserving cost and resource
through an effective preventive maintenance program.
 2. To adopt a system that preventive maintenance for
equipment shall be a part of the Total Quality Assurance
Program of the staff for the technical operation and
management.
B. Preventive maintenance
Involves a regular schedule of cleaning, lubricating, adjusting, testing,
calibrarting, checking for wear and tear and replacing component as required
by the manufacturer or when the need for a change is pparent.
C. Corrective maintenance
Implies repair and rehabilitation to be done by a qualified service
personnel/ engineer or service technician.
1. That the External and Internal Quality precautionary measures shall be
observed by the users such as:
a. Temperature monitoring, see ANNEX ??
b. Regular checking/ cleaning before and after use
c. Proper care, handling storage
2. Sealed centrifuge should be used for spinning materials and operators
should ensure thart the rotor has completely stopped turning before
opening
3. Biological safety cabinets should be used for all procedures likely to
produce aerosols
4. Regular calibration
5. Cover the instrument with dust cover if applicable.

D. Immendiate attention is given to erring equipment and should be reported to a

qualified technician/ engineers who are especially indicated for automated
machines where the service warranty is still available from the manufacturer
or supplier/ company
E. Check electrical requirement/ appliances before plugging into appropriate
outlet. Use AVR, automatic voltage regulator, when necessary.
F. Switch off/ unplug equipment/ appliances after use if necessary
G. Keep all records or repair and/ or maintenance and calibration of machines and
equipments.

CHAPTER 5: Supplies, Materials and

Reagents
To maintain n adequate number and supply of reagents and laboratory
supplies, weekly inventory is done by the Laboratory and Medical staffs assigned to
such task. The following particulars are noted upon receiving/ purchasing the items:

1. ITEM INVENTORY
a. Item description—item code is assigned
b. Packaging
 c. Brand name
d. Lo number
e. Number of tests/ volume/ quantity
f. Price
g. Delivered By
h. Date received/ date delivered
i. Received by
j. Expiration Date
2. SUPPLY INVENTORY
a. Item description with the designated item code
b. Total number of tests
c. Balance (number of tests left from previous monthly inventory)
d. Tests/reagents/ materials consumed depending on the last inventory date
e. Tests/ reagents/ materials left

PART 4
TECHNICAL OPERATING
PROCEDURES OF THE
QUALITY STANDARD SYSTEM
FOR PRE-EMPLOYMENT MEDICAL
SERVICES
To comply with the standard quality embodied in the Assessment Tool for
accreditation of OFW Clinics, yhe following stct guidelines is hereby implemented in
performing the PEME among applicants catered by ASAP DIAGNOSTIC CENTER.

In reference with the Basic DOH Pre-employment Medical Exminations

for overseas work applicants, the following list of examiunations have adopted
 for compliance. (REFERENCES:STANDARDS DEVELOPMENT DIVISION (SDD); Bureau
of Health Facilities and Services (BHFS); Department of Health (DOH); DOH
ADMINISTRATIVE ORDER NO. 2013-0006)

PRE-EMPLOYMENT MEDICAL EXAMINATIONS

FOR OVERSEAS WORK APPLICANTS

BASIC DOH PRE-EMPLOYMENT MEDICAL EXAMINATIONS FOR OVERSEAS

WORK APPLICANTS

ACTIVITY METHOD / TEST

1. Perform History and Physical
Examination
2. Perform Dental Examination
3. Check Visual Acuity
4. Check Color Perception
5. Perform Audiometry (for
seafarers)
6. Perform ECG
7. Perform Chest x-ray (PA View)
8. Perform Blood Typing
9. Perform CBC
10. Perform Test for Syphilis
11. Perform Urinalysis
12. Perform Pregnancy Test (for
female applicants)
13. Perform Stool Examination
(for food handlers)
14. Perform Psychological
Examination (for land-based
overseas work applicants)
Thorough/complete history and physical
examination
Routine dental check up
Use of Snellen’s, Jaeger’s
Ishihara– 24 plates
Pure Tone – Air Conduction
Routine 12- lead ECG
Digital
Routine
Automated with 3-part differential count
RPR and/or TPHA depending on principal’s
requirements
Routine urinalysis and/or automated urine
strip reader with 10 parameter urine strips
Serum pregnancy test
Formalin Ether Concentration Technique
(FECT)
Autobiography, interview and DOH battery of
psychological tests namely: 16 PF Test
and/or BPI
AND RSPM or PNLT or BGVMT

Legend:
CBC – Complete Blood Count
ECG – Electrocardiogram
FECT – Formalin Ether Concentration Technique
RPR – Reactive Plasma Reagin
TPHA – Treponema pallidum Haemagglutination Test
16 PF Test – 16 Personality Factors Test
BPI – Basic Personality Inventory
RSPM – Raven’s Standard Progressive Matrices
PNLT – Purdue Non-Language Test
BGVMT – Bender Gestalt Visual Motor Test
GUIDELINES

a. The table above shows the MINIMUM examinations contained in the basic DOH
PEME package. There is a corresponding column ‘TEST/METHOD’ alongside
each ‘ACTIVITY’ item.

b. The basic DOH PEME package shall be applied to applicants for overseas work.

c. Audiometry, utilizing at least air conduction audiograms, shall be performed on

seafarers and when required by the employer/principal for land based applicants.

d. An ECG shall be performed on seafarers, land based applicants aged 40 years and
above, and whenever PEME findings warrant further investigation.

e. Serological test for syphilis such as RPR and/or TPHA shall be performed in
accordance with host country requirements.

f. A serum pregnancy test shall be performed on all female applicants.

g. Stool examination, using FECT, shall be performed on applicants applying for

positions with food handling/catering services and/or whenever required by the
employer/principal.

h. The validity of psychological tests shall be in sync to the validity of PEME.

1. The minimum battery of psychological tests of DOH shall be applied to land
based overseas work applicants.
2. Applicants for seafaring duty shall undergo psychological examinations
whenever required by the principal and only for psychological tests
prescribed by the employer/principal. The DOH battery of psychological
tests may be applied to seafarer applicants if necessitated by the
employer/principal.
3. The psychological screening and evaluation of the DOH shall include, but
are not limited to, the following: a. Interview;
b. Autobiography;
c. Minimum battery of psychological tests namely:
1. 16 PF Test and/or BPI AND
2. RSPM or PNLT or BGVMT.
4. The assessment report(s) prepared and done by the psychometrician shall
always bear the signature of the supervising psychologist who shall take full
responsibility for the integrity of the report.
5. The psychologist and psychometrician shall be required to indicate his/her
registration and professional identification (ID) card number, the date of ID
issuance and its duration of validity, and the professional tax receipt number
(PTR) on each official document signed or issued in connection with the
practice of the profession. The foregoing is in accordance with Section 22
of R.A. No. 10029 known as the “Philippine Psychology Act of 2009”.

i. Serological testing for blood-borne diseases such as, but not limited to, HIV,
hepatitis B and hepatitis C shall be performed whenever required by the
 principal/employer and in accordance with host country requirements. The
method used shall be at least Enzyme Linked Immunosorbent Assay (ELISA).

j. Reactive screening tests to the above mentioned blood-borne diseases (i.) shall
be confirmed at the National Reference Laboratory (NRL) – STD/AIDS Central
Cooperative Laboratory (SACCL).

k. The applicant shall pay directly to the DOH accredited medical clinic where
PEME is to be conducted except in the case of a seafarer whose medical
examination cost is shouldered by the principal/ship-owner.

NOTES:
1. SERVICE DELIVERY FLOW, SEE ANNEX???
2. FOR THE TECHNICAL STANDARD OPERATING PROCEDURE FOR THE
PERFORMANCE OF KABORATORY TESTS, SEE ATTACH SOP MANUAL OF
CLINICAL LABORATORY

PART 5
INFORMATION MANAGEMENT

ANNEX ???

ASAP DIAGNOSTIC CENTER

ADDRESS:
CONTACT DETAILS:

FEES FOR THE PRE-EMPLOYMENT MEDICAL EXAMINATIONS

FOR OVERSEAS WORK APPLICANTS

BASIC DOH PRE-EMPLOYMENT MEDICAL EXAMINATIONS FOR OVERSEAS

WORK APPLICANTS
ACTIVITY PACKAGE COST
1. Perform History and Physical Examination P

2. Perform Dental Examinations P

3. Check Visual Acuity P
4. Check Color Perception P
6. Perform ECG P
7. Perform Chest x-ray (PA View) P
8. Perform Blood Typing P
9. Perform CBC P
10. Perform Test for Syphilis P
11. Perform Urinalysis P

TOTAL P

ADDITIONAL EXAMINATIONS REQUIRED IF P

NECESSARY:
Perform Audiometry (for seafarers and when P
required for the employer/principal for land-based
applicants)
Perform Serum Pregnancy Test (for female P
applicants)
Perform Stool Examination (for food handlers and/or P
whenever required byt the employer/ principal)
Perform Psychological Examination (for land-based P
overseas work applicants)
Serological testing (ELISA Method) for blood-borne P
diseases (HIV, hepatitis B and hepatitis C)
whenever required by the employer/ principal and
in accordance with host country
GRAND TOTAL P

Prepared by:

Dulce S Piswec, RMT

ASAP DIAGNOSTIC CENTER
CLINIC MANAGER

REFERENCES:
STANDARDS DEVELOPMENT DIVISION (SDD)
Bureau of Health Facilities and Services (BHFS)
Department of Health (DOH)
DOH ADMINISTRATIVE ORDER NO. 2013-0006
 NAME OF CLINIC
DOH ACCREDITATION NUMBER
Clinic Address
Clinic Contact Information
Email Address

MEDICAL CERTIFICATE FOR LANDBASED OVERSEAS

WORKERS
Approved and authorized by the Department Of Health (DOH)

SURNAME/LAST NAME: GIVEN NAME: MIDDLE NAME

AGE: DATE OF BIRTH: PLACE OF BIRTH: NATIONALITY:

DAY MONTH YEAR

GENDER: MALE CIVIL STATUS: SINGLE RELIGION:
FEMALE MARRIED

THIS IS TO CERTIFY THAT A MEDICAL AND PHYSICAL EXAMINATION WAS GIVEN TO:
PHOTO
______________________________________________
(MUG SHOT) (NAME OF APPPLICANT)

RESULT:
PASSPORT SIZE
FIT UNFIT

___________________________________________________
Name and Signature of Examining/Authorized Physician

Date of Examination:__________________________________
OFFICIAL STAMP

Approved by:

___________________________________________________
Medical Director

I HAVE READ AND UNDERSTOOD THE CONTENTS OF THE ABOVE AND THE INTEGRAL NOTES HEREOF.

APPLICANT’S NAME AND SIGNATURE: ________________________________________________________________ DATE: __________________

(THIS SIGNATURE SHOULD BE AFFIXED IN THE PRESENCE OF THE EXAMINING PHYSICIAN)
DATE OF ISSUANCE OF PEME CERTIFICATE: DATE OF EXPIRATION OF PEME CERTIFICATE:
(Filling out this field is not mandatory.)
DAY MONTH YEAR DAY MONTH YEAR
DOH -PEME -LB
Revision:00
05 /21 /2013
Page 1 of 2
ADDRESS:

PASSPORT NUMBER: COUNTRY OF DESTINATION:

POSITION APPLIED FOR: EMPLOYER/COMPANY/RECRUITMENT AGENCY (IF APPLICABLE):

SATISFACTORY HEARING? YES NO

SATISFACTORY SIGHT? YES

NO

SATISFACTORY COLOR VISION? (WHEN REQUIRED)

YES NO

SATISFACTORY PSYCHOLOGICAL TEST? YES

NO

IS APPLICANT SUFFERING FROM ANY MEDICAL CONDITION LIKELY TO BE AGGRAVAT ED BY LANDBASED O VERSEAS WORK OR TO RENDER THE
APPLICANT
UNFIT FOR SUCH SERVICE OR TO ENDANGER THE HEALTH OF OTHER PERSONS?

YES
NO

IMPORTANT INTEGRAL NOTES

1. Details of any medical condition identified or test results other than those listed
herein are not recorded in this Certificate.

2. A Medical Examination Report (MER) containing the medical history, clinical findings
and other diagnostic tests and results of the applicant is contained in a separate
document in compliance with DOH Guidelines and the host country/ principal’s
requirements.

3. This certificate is neither a certificate of general health nor a certification of the

absence of illness. It is a confirmation that the applicant is expected to be able to
meet the minimum requirements for performing his/her duties specific to their job
overseas safely and effectively.
 4. This medical certificate shall be valid for a maximum period of ninety (90) days prior
to deployment, subject to physician’s recommendations and/or principal’s
requirements.

5. An applicant who has been refused a medical certificate or has had a limitation
imposed on his/her ability to work, shall be given the opportunity to have an
additional examination by another medical practitioner or medical referee who is
independent of the principal or of any organization.

DOH-
PEME-LB
Revision:00
05/21/2013
Page 2 of 2
SPECIFICATIONS OF AND INSTRUCTIONS ON HOW TO
ACCOMPLISH
ANNEX – C “MEDICAL CERTIFICATE FOR LANDBASED
OVERSEAS WORKERS”

1. Use only size A4 bond paper with a MINIMUM of substance 20.

2. Use only one (1) sheet of bond paper with the following back to
back information:

a. Front page – MEDICAL CERTIFICATE FOR LANDBASED

OVERSEAS WORKERS;
b. Back page – contains the IMPORTANT INTEGRAL NOTES.
3. Use only English language.
4. Use only black ink.
5. Use only white background.
6. The applicant’s photo shall be digitized.
7. The Official Stamp or Clinic Logo may be in color but the clinic
name and information must be in black.

8. Security features are allowed.

9. Kindly put a check mark (✓) on the appropriate box and
enter all data called for. Do not leave any item blank.

10. The applicant shall affix his/her signature in the presence of

the examining physician.

11. The signature of the examining physician shall be original

and/or in accordance with the E-Commerce Law.

Approved by:
 (sgn’d) ATTY. NICOLAS B. LUTERO III, CESO III
Assistant Secretary
Department of Health

A.O. No. 2013-0006

NAME OF CLINIC
Address
Contact
Informa
tion E-
mail
address

HUMAN IMMUNODEFICIENCY VIRUS (HIV)

SCREENING TEST
CERTIFICATE

This is to certify that

Mr./Ms._______________________________________________ has undergone
screening test for HIV/Acquired Immunodeficiency Syndrome (AIDS), and was found
to be Non-Reactive*/Reactive* based on laboratory test (HIV-1/HIV-2).

______________________________
Examining Physician
License
Picture No._____________________
Date of
Medical Examination _______

LABORATORY REPORT

Date:
______________

Name: ________________________________________________ Age: _______ Sex: ______ Civil Status:

____________
Address:
__________________________________________________________________________________________
_

Human Immunodeficiency Virus Types I (HIV-I) and (HIV-2) as a screening test for HIV/AIDS:

Screening Test Used: (please check)

RAPID

Particle Agglutination

EIA / CMIA / ELFA

Others (specify) _________

RESULT * NONREACTIVE REACTIVE

________________________________
Medical Technologist
HIV Proficiency Cert. No.___________
Expiry date ______________________

________________________________
Pathologist

__________________________________________________________________________________________
__________
*A non-reactive result indicates that the tested sample does not contain detectable Human Immunodeficiency Virus (HIV) antibody. This
does not preclude the possibility of recent exposure to an infection by HIV.
MFOWS-Annex I-HIVST
Revision:01
06/08/2011

Year________
ANNUAL REPORT ON CASES OF REPATRIAT
Name of Clinic:
__________________________________________________________________________________________
Complete Address: ______________________ Contact Nos.______________ Fax No.______ E-mail Address
_____________
Classification of Clinic (Please check): Regular Land based and Sea based ______ Special Sea based _____ Special Land
based________

Instructions: Fill out the tables properly and accurately. Put NA, if not applicable.

Table 1. Number of Cases of Repatriation for Land Based Workers

Name Ag Date Job Country Employer/ Date of Date of Cause(s) Final

of e Se of Applie of Company/ Deployme Repatriatio of Diagnos
Worke x PEME d For Destinatio Recruitme nt n Repatriatio is (if
r * n nt Agency, n availabl
if any e)

Legend: PEME – Pre-Employment Medical Examination

 Table 2. Number of Cases of Repatriation for
Seafarers

orker Age Sex Date of Position Company Vessel Type Sea Trade Date of Date of Cause(s) of
PEME* Applied (Cruise, Cargo, (Offshore, Deployment Repatriation Repatriation Di
For Tanker, Seismic) Coastal) a

Legend: PEME – Pre-Employment Medical Examination

Prepared by: ______________________________ Certified Correct:

______________________________
Signature over Printed Name Medical
Director
______________________________
_____________________
Designation Date

Month __________Year________
MONTHLY STATISTICAL REPORT ON SELECTED
LABORATORY TESTS
Name of Clinic:
__________________________________________________________________________________
______________
Address: __________________________________ Contact Nos._________ Fax No. _______ E-
mail Address: _________________
Classification of Clinic (Please check): Regular Land based and Sea based _____ Special Sea based
_____ Special Land based_____

Instructions: Fill out the tables properly and accurately. Put NA, if not applicable.

Table 1. Number and Results of Selected Laboratory Tests Performed on

Land Based Workers

RPR Confirme HIV Test Confirme Hepatitis Confirme Hepatitis Confirme Nam Drug Confirme
d d -B d -C d e of Test d
Positive Positive (HBV) Positive (HCV) Positive Drug Positive
to TPHA to HIV to HBV to HCV to
Drug(s)
Tota R Tota R Tota R Tota R Tota R
l * l l l l

Legend: * R – Reactive

Table 2. Number and Results of Selected Laboratory Tests

Performed on Seafarers
RPR Confirme HIV Test Confirme Hepatitis Confirme Hepatitis Confirme Nam Drug Confirme
d d -B d -C d e of Test d
Positive Positive (HBV) Positive (HCV) Positive Drug Positive
to TPHA to HIV to HBV to HCV to
Drug(s)
 Tota R Tota R Tota R Tota R Tota R
l * l l l l
1.
2.

Legend: * R – Reactive

Prepared by: ______________________________ Validated by:

______________________________________
Signature over Printed Name Medical
Director
______________________________
_____________________
Designation
Date

Month __________Year________
MONTHLY STATISTICAL REPORT ON PRE-EMPLOYMEN
EXAMINATION Clinic:
(PEME)
Name of
____________________________________________________________________________________________________
______________________
Address : _____________________________Contact Numbers: _________________ Fax No.________ E-mail
Address ________________________________
Classification of Clinic (Please check): Regular Land based and Sea based_____________ Special Sea
based____________ Special Land based ____________

Instructions: Fill out the tables properly and accurately. Put NA, if not applicable. Use additional sheets whenever necessary.

Table 1. Number of UNFIT PEME Certificates Issued to LAND BASED work Applicants and Reasons for UNFITNESS

REASONS FOR UNFITNESS Number

TOTAL UNFIT

Total number of FIT PEME Certificates issued to land based work applicants: ____________________

Table 2. Number of UNFIT PEME Certificates Issued to SEAFARER Applicants and Reasons for UNFITNESS

REASONS FOR UNFITNESS Number

TOTAL UNFIT

Total number of FIT PEME Certificates issued to seafarer applicants: ____________________

Prepared by: ____________________________________ Validated by:

______________________________
Signature over Printed Name Medical
Director
 ____________________________________
______________________________
Designation
Date
 Republic of the Philippines
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
ANNEX – J
A. O. No. 2013-0006
DOH MASTER LOGBOOK

DATE NAME OF AGE/ EMPLOYER / COMPANY / EXAMINATIONS CONDUCTED REMARKS SIGNATURE

EXAMINEE SEX AGENCY OF EXAMINEE
 MFOWS-Annex J- Master Logbook
Revision: 00
Note: Make Monthly Summary Report 07/18/2013
Page __ of __