1
FIT TO WORK CERTIFICATE
Name & Surname:
Date of Birth:
ID/Passport No:
Please provide details/numbers for:
Blood type:
Blood pressure:
Pulse:
BMI:
Electrocardiogram (ECG)
For applicants over 45 years
Please provide information here:
Other comments
Please state comments here:
On the basis of the signed Medical Declaration [ANNEX I] and the medical examination which
I carried out on ____/____/_________, hereby I certify that the above-mentioned person has
been found to be in good health, without any medical limitations and therefore medically fit to
travel and work abroad for an international mission, possibly in a post-conflict environment,
that may present the following characteristics:
Tropical weather conditions (high temperatures/humidity) or cold dry weather conditions
High altitude
Work under stressful situations which may involve long working hours
Mosquito borne diseases
Water-borne diseases
Limited dietary choices
Basic amenities available
Doctor’ Name & Surname:
Signature & Stamp:
Date & Place:
Email:
Tel:
Ref. Ares(2020)5166687 - 01/10/2020
2
ANNEX I
MEDICAL DECLARATION
[to be filled by the involved person]
Do you suffer from or have you ever suffered from, had symptoms of, been examined for or been
treated for any of the following ailments, or anything related to them? Consider the examples as
help - they do not cover all conditions. Any other symptoms or ailments must also be stated, and a
clarification and further details should be written on the last page.
If yes; what and when:
What was the outcome of the treatment?
Is the treatment ongoing, completed or recurrent?
Yes:
No:
If yes; what and when:
What was the outcome of the treatment?
Is the treatment ongoing, completed or recurrent?
Yes:
No:
If yes; what and when:
What was the outcome of the treatment?
Is the treatment ongoing, completed or recurrent?
Yes:
No:
If yes; what and when:
What was the outcome of the treatment ?
Is the treatment ongoing, completed or recurrent?
Yes:
No:
If yes; what and when:
What was the outcome of the treatment ?
Is the treatment ongoing, completed or recurrent?
3
I, the undersigned, hereby declare that:
- All information provided in this Medical Declaration Form is correct to the best of
my knowledge, and that no information concerning my past or present health has
been withheld;
- This medical declaration has been provided to my physician prior to obtaining the
Fit to Work Certificate;
- In the event of apparent change of my medical condition, I understand that I am
obliged to update my fit-to-work certificate.
Name & Surname:
Date of Birth:
ID/Passport No:
Signature:
Date and Place:
Yes:
No:
Yes:
No:
If yes, what kind?
Yes:
No:
If yes, what kind of medicine and for what reason:
Yes:
No:
If yes; for what and when?
If yes, is the treatment ongoing or are you cured?
Please state comments here: