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Health Declaration Form

The document provides clarification on changes made to the Health Declaration Form that international students must submit for their visa applications. It details the implementation of the updates, including ensuring the applicant's name, signature and passport number match the information provided. It also explains applicants must indicate if they are free of listed diseases/conditions, or specify any they have. Those diagnosed must submit a medical report. The updated form is also included.

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Dinesh Kumar
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271 views

Health Declaration Form

The document provides clarification on changes made to the Health Declaration Form that international students must submit for their visa applications. It details the implementation of the updates, including ensuring the applicant's name, signature and passport number match the information provided. It also explains applicants must indicate if they are free of listed diseases/conditions, or specify any they have. Those diagnosed must submit a medical report. The updated form is also included.

Uploaded by

Dinesh Kumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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EDUCATION MALAYSIA GLOBAL SERVICES (EMGS)

21st June 2019

NOTICE ON THE CHANGES MADE TO THE HEALTH DECLARATION FORM FOR


INTERNATIONAL STUDENTS

1. PURPOSE

1.1 This information is intended to provide clarification to all Education Institutions and
International Students regarding the updates / changes in the ‘Health Declaration
Form’. (Refer to Lampiran B)

1.2 Based on the previous bulletin that was sent on 4 th June 2019, all International
Students are required to submit a ‘Health Declaration Form’ for their VAL
applications.

2. IMPLEMENTATION

2.1 The applicants are required to ensure the following details are completed in the
‘Health Declaration Form’: -

▪ Date – Must be filled in dd/mm/yyyy format i.e. 20/06/2019

▪ Name of Applicant – Must be the same as indicated in the passport

▪ Applicant’s Signature is required

▪ Applicant’s Passport Number – Must be the same as indicated in the applicant’


passport copy submitted for Visa Approval Letter (VAL) application.

2.2 If the applicant is free from any of the listed diseases / conditions, please proceed
to tick under the ‘YES’ column. Below is an example that indicates an applicant
that has declared he / she is free from any of the listed diseases / conditions: -
I hereby declare that I am free from the following diseases/conditions:

SELF IF NO, PLEASE


ITEMS
YES NO STATE IF YOU HAVE
SOUGHT
Tuberculosis ✓ CONSULTATION
Hepatitis B ✓ FOR ANY OF THE
✓ LISTED
Hepatitis C
DISEASES/CONDITI
HIV ✓ ON, YOU ARE
Drug use/abuse of: REQUIRED TO
SUBMIT YOUR
1. Opiates ✓
MEDICAL
2. Cannabinoids ✓ HISTORY/REPORT
3. Amphetamine ✓ FROM YOUR
TREATING
4. Methamphetamine ✓
PHYSICIAN TO
Sexually Transmitted Diseases ✓ EDUCATION
Congenital or Inherited Disorder ✓ MALAYSIA GLOBAL
SERVICES (EMGS)
Cancer ✓ PANEL
Epilepsy ✓ CLINIC/UNIVERSITY
Psychiatric Illness ✓ HEALTH CENTRE.

Other illness ✓

2.3 If the applicant is diagnosed with one or more of the listed diseases / conditions,
please proceed to tick under the ‘NO’ column. Below is an example that indicates
an applicant that has declared he / she is not free from one or more of the listed
diseases / conditions: -

I hereby declare that I am free from the following diseases/conditions:

SELF IF NO, PLEASE


ITEMS
YES NO STATE IF YOU HAVE
SOUGHT
Tuberculosis ✓ CONSULTATION
Hepatitis B ✓ FOR ANY OF THE
✓ LISTED
Hepatitis C
DISEASES/CONDITI
HIV ✓ ON, YOU ARE
Drug use/abuse of: REQUIRED TO
SUBMIT YOUR
1. Opiates ✓
MEDICAL
2. Cannabinoids ✓ HISTORY/REPORT
3. Amphetamine ✓ FROM YOUR
TREATING
4. Methamphetamine ✓
PHYSICIAN TO
Sexually Transmitted Diseases ✓ EDUCATION
Congenital or Inherited Disorder ✓ MALAYSIA GLOBAL
SERVICES (EMGS)
Cancer ✓ PANEL
Epilepsy ✓ CLINIC/UNIVERSITY
Psychiatric Illness ✓ HEALTH CENTRE.

Other illness ✓

2.4 Kindly ensure all information requested in this form is complete and updated in
the English Language.

Education Malaysia Global Services


21st June 2019
HEALTH DECLARATION FORM FOR APPLICANTS

I hereby declare that I am free from the following diseases/conditions:

SELF IF NO, PLEASE


ITEMS
YES NO STATE
Tuberculosis
Hepatitis B
IF YOU HAVE SOUGHT
Hepatitis C
CONSULTATION FOR
HIV ANY OF THE LISTED
Drug use/abuse of: DISEASES/CONDITION,
YOU ARE REQUIRED
1. Opiates TO SUBMIT YOUR
2. Cannabinoids MEDICAL
HISTORY/REPORT
3. Amphetamine FROM YOUR TREATING
4. Methamphetamine PHYSICIAN TO
Sexually Transmitted EDUCATION MALAYSIA
GLOBAL SERVICES
Diseases (EMGS) PANEL
Congenital or Inherited CLINIC/UNIVERSITY
Disorder HEALTH CENTRE.

Cancer
Epilepsy
Psychiatric Illness
Other illness
I declare that I will submit myself for compulsory Post-Arrival Health Examination as per
Malaysian regulations. In the event that I should be diagnosed with any condition that deems me
UNSUITABLE for studies, I will bear the cost of leaving Malaysia and will adhere to the
immigration requirements on the visit pass and exit before the pass expiration, or any deadline
given to me whichever is earlier.

I declare that in the event I should be diagnosed with any conditions that does not require my
removal from Malaysia but requires medical treatment and I choose to remain in Malaysia to
continue my studies, I will bear any and all costs relating directly or indirectly towards the medical
management of my medical condition.

I confirm that EMGS Panel Clinic/University Health Centre shall not be responsible in any manner
or whatsoever, arising out of EMGS Panel Clinic/University Health Centre certification of my
medical status as suitable to study or reside in Malaysia despite the medical condition described
above. I further undertake to hold EMGS Panel Clinic/University Health Centre harmless from
any loss or liability arising from this decision and agree to indemnify and keep EMGS Panel
Clinic/University Health Centre from any loss or liability arising from this decision.

………………………… …………..……………………………………………
Date (dd/mm/yyyy) Name of applicant as indicated in the passport

………………………… …………………………………………………………
Applicant’s signature Applicant’s passport number

Kindly ensure all information requested in this form is complete and updated in English Language.

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