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Admission Booklet Semester 1, 2012/2013 Session

Undergraduate Programme

(Malaysian Qualifications)

ACADEMIC MANAGEMENT AND ADMISSION DIVISION

INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

P.O.Box 10, 50728 KUALA LUMPUR

Tel: 603-6196 4000 ext: 3991/4040/4047/4048

Fax: 603-6196 4724

E-mail: admissions@iium.edu.my

IIUM website : http://www.iium.edu.my

WELCOME TO THE INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

“THE GARDEN OF KNOWLEDGE AND VIRTUE”

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Table of contents

No. Items Page 1. Welcoming Message from the Dean of the

Academic Management and Admission Division

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2. Terms and Conditions of Offer and Registration

4 - 7

3. Mahallah Registration

8

4. Student Financial Assistance Services

9 - 13

5. Welcoming Remarks - From the chairman of “Ta’aruf Week” Programme

14 -15

6. Medical Check-up Form

16 - 20

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Dear Students, We are very pleased to welcome you to the International Islamic University Malaysia (IIUM). We

would like to take this opportunity to congratulate you on getting a place at this University. We

can assure you that IIUM has an exciting educational program awaiting you. We trust you will find

your time here rewarding and complimentary to your personal and professional goals.

At IIUM, we are blessed with beautiful surroundings. We are sure you will enjoy the beauty of our

campus and appreciate the opportunity to study at this great university. The state-of-the-art

program will equip you with the skills you need to gain control over your own destiny.

Over the years, the University has built a strong reputation as one of the leading Universities in

the Islamic world. We achieved this by exercising a tradition that fosters excellence and unity in

diversity.

We are delighted that you have selected the International Islamic University Malaysia. We look

forward to greeting you in person.

May Allah S.W.T bless all of us.

ASST. PROF. DR. SHAMSUL JAMILI YEOB Dean Academic Management and Admission Division

WELCOMING MESSAGE FROM THE DEAN OF THE ACADEMIC MANAGEMENT AND ADMISSION DIVISION

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TERMS AND CONDITIONS OF OFFER AND REGISTRATION

(SESSION 2012/2013)

CONGRATULATIONS for being selected to join the International Islamic University Malaysia and welcome to the Garden of Knowledge and Virtue. This information is provided to prepare you for registration at the University. Please read carefully and follow the instructions given. 1. ACCEPTANCE/REJECTION OF OFFER

1.1 You are requested to accept or reject our offer at

http://www.iium.edu.my/kemasukan/tawaran/ within the stipulated period as stated in the offer letter, otherwise this offer of admission will be automatically revoked.

1.2 If you decided to reject our offer, please take note that you may not be considered for

admission into the Undergraduate programme in the future and no further appeal for admission will be entertained.

1.3 If you accepted the offer but wish to defer the registration for up to one year due to valid

reasons acceptable by the University, please submit an official letter to the following address prior to the commencement of the semester for which this offer of admission was given:

Dean, Academic Management and Admission Division, International Islamic University Malaysia,

P.O. BOX 10, 50728 Kuala Lumpur

1.4 If you have any enquiries, please feel free to contact us at : Telephone Number : 03 – 6196 4000 Extension : 3990 / 4040 / 4047 / 4048 Fax No. : 03 – 6196 4724 2. FEES AND CHARGES

Please refer to the following website for the details: http://www2.iium.edu.my/finance/services/available-services-0

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3. REGISTRATION

For the purpose of registration, please bring along the following documents for verification by the University authority :

CATEGORY DOCUMENTS ORIGINAL OR PHOTOCOPY

STPM / STAM / ASASI (A/S/L/U/N/T)

i. On-line Offer Letter ii. Identity Card

iii. Birth Certificate iv. School Leaving Certificate v. SPM/’O’ Level Certificate

vi. STPM/STAM/ ’A’ Level/or equivalent. vii. Academic Transcript for Asasi Programme viii. MUET result (latest)

ORIGINAL & PHOTOCOPY

Diploma (E/F) i. On-line Offer Letter ii. Identity Card

iii. Birth Certificate iv. School Leaving Certificate v. SPM/’O’ Level Certificate

vi. STPM/STAM/ ’A’ Level/or equivalent ( if any) vii. Academic Transcript for Diploma Programme viii. MUET result (latest)

ORIGINAL

All Students i. Bank-in slip of your payment of entrance fees ii. Six (6) of your recent photographs measuring

3cm X 3.5cm with your name, Matric No. and offered programme be written at the back of every photograph. You are required to submit them to the following Division/Unit/Centre. a) Academic Management and Admission

Division - 2 photographs b) Hostel and Residential Unit - 2 photographs c) Office of The Health and Wellness Centre - 2

photographs (One of them to be pasted on the IIUM medical check-up form)

No student will be allowed to register without producing original documents on the Registration Day. If the University authority discovers the use of false declaration or use of forged certificates or documents by any student for gaining entry to the University, the student concerned will be dismissed from the University and the University may at its absolute discretion take legal action against any student guilty of committing forgery or fraud.

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4. MEDICAL CHECK-UP AND X-RAY

4.1 Students are required to have their X-Ray and report done prior to the registration day and to bring the X-Ray film and report during the Medical Check-up appointment. Please also bring along the Medical Check-up Form during the appointment.

4.2 Please fill in Part 1 and 2 of the IIUM Medical Check-up Form. The remaining parts will only be filled in by the IIUM Medical Officer.

4.3 Only the IIUM Medical Doctors have the right to perform the Medical Check-up upon your arrival at this University (as in Part 3, 4 and 5 of the IIUM Medical Check-up Form). In cases where you have consulted a Medical Doctor other than the IIUM Medical Doctor, and have filled in Part 3, 4 and 5 of the IIUM Medical Check-up Form, the University has the right to reject such a form.

5. TA’ARUF (ORIENTATION) PROGRAMME (Compulsory to all new students) All students are required to attend Ta’aruf programme conducted by the University. Please read “Welcoming Notes from the Chairman of Ta’aruf Week” for details.

6. ENGLISH PLACEMENT TEST (EPT) 6.1 All new students are required to sit for the English Placement Test (EPT). However, an

exemption will be given if you can present a score of 550 (paper-based) or 213 (computer based) in the Test of English as a Foreign Language (TOEFL) or overall Band 6.0 in the test administered by the International Language Testing Service (IELTS).

6.2 The EPT test will be conducted during the Ta’aruf programme. If you do not achieve the minimum score set by the University (for programmes that use English as a medium of instruction), you are required to undergo the Pre-Sessional Programme (PRSS) before proceeding to the respective programme of studies and pay the tuition and academic administrative fees while in the programme. The maximum duration of Pre-Sessional Programme (PRSS) is two (2) years. Please refer to (http://www.iium.edu.my/celpad/temu) for more details.

7. ARABIC PLACEMENT TEST (APT)

All new students are required to sit for the Arabic Placement Test (APT). The test will be conducted during the Ta’aruf programme. Those who do not achieve the minimum score set by the University are required to do Pre-Sessional Programme (PRSS) before proceeding to the respective programmes of studies that use Arabic as a medium of instruction (applicable to Arabic Language & Literature and Islamic Revealed Knowledge & Heritage programmes only). The maximum duration of the Pre-Sessional Programme (PRSS) is two (2) years. The students are also required to pay the tuition and academic administrative fees while in the programme

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8. TILAWAH PLACEMENT TEST (TPT) All new students are required to sit for the Tilawah Placement Test (TPT) to determine their level of recitation and understanding of Taj’wid. There are two levels that students have to fulfill as their graduation requirements. The test will be conducted during the Ta’aruf programme. Those who are exempted from the first level may proceed to the second level.

9. PERSONALITY AND CONDUCT IIUM aims at producing professionals who practice Islamic teachings sincerely, are God-fearing and who are equipped with a balanced personality. Hence, all students are required to obey the University regulations and to behave in accordance with Islamic teachings based on the Quran and Sunnah at all times on or off campus.

Should any students behave otherwise he or she may be dismissed from the University.

10. DRESS CODE 10.1 Please refer to the following website for the details:

http://www.iium.edu.my/legalunit/articles-4

10.2 Attire on the Registration Day and Ta’aruf Week

i. MALE

Long sleeve shirt.

Dark coloured trousers

Dark coloured shoes

ii. FEMALE

Wear ‘Mini Telekong’ or Head cover

‘Baju Kurung’ or dress which covers the aurah

White ‘Sarong’ for special occasion during the Ta’aruf week.

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MAHALLAH REGISTRATION (HOSTEL)

All undergraduate students are required to register

with mahallah. Application to stay off campus may

come later after the the Ta’aruf Week. Fail to register

with the mahallah may due to compoundable offence

at the maximum rate of RM50.

Please bring along 2 photographs (passport size)

for mahallah registration at the assigned mahallah.

For further information, please visit the mahallah

website at :

http://www2.iium.edu.my/stadd/about-us/units-departments

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STUDENT FINANCIAL ASSISTANCE SERVICES

OPEN FOR ALL REGISTERED FULL TIME STUDENTS OF IIUM (Malaysian & International)

MAJOR TYPES OF FINANCIAL ASSISTANCE AVAILABLE

IIUM UMMATIC SCHOLARSHIP The IIUM Undergraduate Ummatic Scholarship is a scholarship awarded to poor, needy, deserving and academically outstanding students, in recognition of their achievement, to study at IIUM. Who Can Apply? Students with excellent academic standing (CGPA 3.6 and above/region/field of study)

What Is Covered?

All fees incur by the University i.e. entrance fee, tuition fee, related fee, monthly allowance, hostel fees and book allowance. Selection process i) Before Enrollment Identified upon admission process as determined by Scholarship Committee (the process is done by the University Authority) ii) After enrollment Obtaining first semester result with CGPA 3.6 and above based on the University general academic workload policy Note: Students from Muslim minority countries with lower CGPA (at least CGPA 3.0) also may apply for the scholarship. IIUM ACADEMIC EXCELLENCE AWARD Who Can Apply? 1. All active students (senior and new intake)

2. Students with excellence academic standing with CGPA 3.8 and above based on the University

general academic workload policy

3. Self-sponsored and loan recipient only (please attached the loan offer letter)

What Is Covered? Exemption from tuition fee only POSTGRADUATE SCHOLARSHIP IIUM Ummatic Scholarship

IIUM Endowment Fund

IIUM Scholarship—Niche Area

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Note: IIUM reserved the right to change the term and condition whenever deemed necessary without prior notice. OTHER MALAYSIA GOVERNMENT EDUCATION FINANCIAL AIDS 1. PTPTN LOAN

a) Eligibility for Application

Malaysian citizen

Undergraduate & Postgraduate

b) Type of Loan

Full loan (cover tuition, related, hostel, cost of living & book allowances)

Parents net income with RM4000 and less

Partial loan (cover tuition, related & hostel fees)

Parents net income between RM4001 -RM5000

Tuition fee (cover tuition fees)

Parents net income RM5001 and above

c) Period of loan

Normal duration of study period for each UG & PG programmes.

d) Suspension of loan / Termination

Obtain GPA below 2.0 / study leave / dismissal

e) Extension of loan

Changes of program structure by the University which involved extra credits

Study leave (Personal / medical reason approved by the University)

f) Application

Online application at: http://www.ptptn.gov.my * Subject to the online application schedule and changes of Rules and Regulations by PTPTN.

2. MALAYSIA PUBLIC SERVICE DEPT. SCHOLARSHIP (JPA)

1. Eligibility for Application

Malaysian citizen

Full time UG student

2. Application

Online application at: http://esilav2.jpa.gov.my/ * Subject to the online application scheduled and changes of Rules and Regulations by JPA

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3. MINISTRY OF HIGHER EDUCATION MALAYSIA

Malaysian International Scholarship (MIS) for Undergraduate and Postgraduate studies.

MTCP Scholarship for Postgraduate studies.

Commonwealth Scholarship & Fellowship Plan for students from the Commonwealth

countries to study at the postgraduate level.

Application: Online application at: http://www.portal.mohe.gov.my OTHER SCHOLARSHIP / LOAN There are many scholarships / loans offered by various government / private agencies. Students may apply directly to the said sponsors upon advertisement. The selection criteria are subject to the requirements of each individual sponsor. WELFARE SERVICES Among the services being rendered to the students are as follows:

A) KHAIRAT Objective:

To assist students who are in dire need of financial assistance and who face difficulties while studying in IIUM

Eligibility:

Death of biological parents / children / husband / wife

Death of IIUM student

Victim of natural calamities (i.e: landslide, fire, flood, etc)

Theft case

Sick student (hospitalized / handicapped / chronic illness)

Poor & needy student

B) FINANCIAL ADVANCE LOAN Objective:

To assist student to relief their financial difficulties so that it will not affect their academic performance Eligibility:

Late receiving of scholarship / financial assistance

Suspension of scholarship / financial assistance due to low GPA

Terms & Conditions:

Full time & registered student

Sponsored student only o Repayment is done through deduction of sponsorship by Finance Division and must be

settled before graduation

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C) MARRIAGE LOAN

Objective:

To ease the burden of students who are ready to get married

To show our concern and support on their good intentions Terms & Conditions:

All registered & sponsored students only o Repayment is done through deduction of sponsorship by Finance Division and the

payment must be settled before graduation

Application to be submitted within 3 months before the ceremony & attach a copy of pre-marriage course certificate

D) INSURANCE COVERAGE & CLAIMS

Objective:

To ensure that the students’ welfare are looked into and they are insured for any bodily injury and/or death caused by accidental means

Source of Insurance

All registered IIUM students are required to pay RM5.00 per year upon their admission or registration and the amount is non refundable

Group Personal Accident (GPA)

All IIUM students (Malaysian and International) are insured under the Group personal Accident Insurance by designated insurance company. However, International students from the matric no. 091xxxx onwards are covered under Medical Health Insurance.

Insurance will be paid to students for cases such as bodily injury and death caused by accidental means

Natural death is not included in the claim. E) MEDICAL HEALTH INSURANCE

All IIUM International students (matric no. from 091xxxx onwards) are insured under the Medical Health Insurance by the designated insurance company.

This scheme is optional to other international students, with the requirement that they should pay RM300.00 per year for the coverage.

The coverage are:

1. Group Personal Accident (GPA) 2. Group Term Takaful (GTT) 3. Group Medical Takaful (GMT)

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F) STUDENT ASSISTANTSHIP PROGRAM

Students can obtain information pertaining to part-time employment in the campus

through advertisement at K/C/D/I

Vacancies offered such as Administrative Assistant, Library Assistant, Graduate

Teaching Assistant, Graduate Research Assistant and Graduate Administrative

Assistant

G) DISABLED STUDENTS

Disabled students should registered at Welfare Unit for allowance claim from Ministry of Higher Education (for Malaysian only)

Assistance given such as transportation services, placement at Mahallah, specific parking lot and others which is based on students’ needs.

FOR FURTHER INQUIRY,

WELFARE UNIT STUDENT AFFAIRS AND DEVELOPMENT DIVISION:

TEL: 03-61964000 EXT. 4118/4401/3656 H) ZAKAT

1. Eligibility for Application

Must be registered as fulltime UG /PG students

Poor & needy 2. What Is Covered?

Living allowance only

3. Application Forms are available at the following offices: a) Gombak & Kl Campus - Zakat & Training Services Unit b) Kuantan Campus - One Stop Student Centre c) CFS - Residential Management & Discipline Department

FOR FURTHER INQUIRY: IIUM ENDOWMENT FUND

TEL NO: 03 61964000 EXTENSION : 4133/ 5315/ 5312

FAX NO: 03 6196 4269

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WELCOMING NOTES FROM

THE CHAIRMAN OF “TA’ARUF WEEK”

السالم عليكن ورحمة ّللاه وبركاته

Welcome/ Ahlan Wa Sahlan/ Salam Sejahtera

Dear students,

Congratulations and welcome to the IIUM, Garden of Knowledge and Virtue. The day when you register as

a student of this University is the day you become part of its big family. This is the place where you are able

to experience diverse cultures from all over the world and meet with people from different backgrounds

while pursuing your degree. The University‘s mission is to achieve Comprehensive Excellence in all aspects

of education, through the process of Integration, Islamisation and Internationalisation (IIICE @ Triple ICE).

Hence, we look forward to seeing you in the orientation programme called Ta’aruf (‘acquaintance’). IIUM

attempts on three students’ enrollments annually and we are expecting new faces from all over the world to

join us. The Ta’aruf secretariat as well as the selected senior students are ready to welcome and assist you

during this time, so that you can familiarise yourself with the campus activities and infra, its academic

requirements and its college life.

We have arranged various activities for you including the Welcoming Session, riadhah activities,

introductory briefing on academic matters, services and facilities, spiritual activities and many more.

BEFORE YOU ARRIVE

Remember to plan your journey accordingly to avoid traffic peak time. Please help us to help you undergo a

smooth enrollment process by following the guidelines and instructions given to you. And remember; do

check all your documents thoroughly before coming. To be specific, prepare a check-list before departure.

Please take note that you are required to wear proper attire throughout the Ta'aruf Programme. The

programme will proffer various information required by new students throughout their studies in this

University.

WHAT TO BRING AND WHAT NOT TO

You are advised to bring only the basic necessities that will facilitate your college life. We are proud to say

that the University provides comfortable accommodation for all students. You are provided with a bed, a

mattress, a wardrobe, a study table and a bookshelf. As such you may need to bring your own pillows,

pillowcases, bed sheets and padlocks for your wardrobe. Convenient stores are aplenty on campus should

you require anything else.

You are also required to bring your sport/outdoor garments during the Ta’aruf Programme. So, you may

need to have proper shoes for riadhah activities, plain collar T-shirts (for Male), long-sleeved & loose T-

shirts (for Female) and your track bottom or tracksuit.

You are allowed to bring other needful items such as personal computers, small radios and perhaps an iron.

However, electrical items such as TV sets, hi-fi systems, and rice cookers are strictly prohibited. Students

are solely responsible for their personal items.

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WHAT TO WEAR

Being an Islamic institution, the University expects its students to adhere to the University dress-code for

both Muslim and non-Muslim students. Non- Muslim students are required to dress with due respect to the

Islamic environment of the University. Female students must cover their aurah and avoid transparent and

tight-fitting clothes.

In short, all students should wear decent clothes and NO jeans are allowed. For male students, your hair

must be kept neat and short. Please bring your long-sleeve shirts and slacks (at least 2 pairs) as it will be

used throughout the Ta'aruf programme. Those who refuse to comply with the University’s rules and

regulations will not be allowed to register.

UPON ARRIVAL

Our campus is serenely beautiful. We are proud with the green landscape of our University area. It is located

far away from the business and chaotic life of the city. The campus is surrounded by green hills, with lakes

and streams running through it.

The first day on campus may be one of the most memorable days of your life. We welcome parents and

family members to send their beloved children during the registration period. However, we would advise

students to be reasonable in this matter, in order to create a more conducive and comfortable environment to

all quarters and to avoid traffic congestion around the University. Furthermore, please take note that the

students will be placed at the permanent mahallat throughout the Ta’aruf programme and they will be no

relocation to other mahallat as the Ta’aruf Programme ends.

Please read all the guidelines given to you so that you are well informed of the Ta’aruf Programme. If you

have any further enquiry, you may contact us at +603-6196 4000 ext 5467/3629 (Br. Hj. Mohd Azmi

Ibrahim/Sr. Azlina Abdul Talib) Secretariats for Ta’aruf Week Programme.

THE DAYS BEYOND

As an IIUM student, we offer many activities besides your academic learning. You may join various

students’ associations, clubs and societies in IIUM. You can help those in need through community service

programmes or even cultivate your talents through debates, arts and cultural activities, which are duly

supported by the Student Development Division. We also have a wide range of sports facilities, from squash

courts to Olympic-sized swimming pools readily available for all students in the Male and Female Sport

Complexes. The Female Sport Complex is restricted only to female students.

We also welcome you to various programmes for spiritual enhancement. You can take part in various

religious activities throughout your study life at the University.

We look forward to meeting you at the International Islamic University Malaysia “TA’ARUF WEEK.”

السالمو , “Garden of Knowledge & Virtue”

DR. AKMAL KHUZAIRY ABDUL RAHMAN

Dean Student Affairs & Development Division cum Chairman of “Ta’aruf Week” International Islamic University Malaysia

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(Please complete Part 1 and 2 only. Part 3, 4 and 5 are to be filled by the IIUM Medical Officer only)

INSTRUCTION: PLEASE FILL IN CAPITAL LETTERS / ARAHAN: SILA ISI DALAM HURUF BESAR

CANDIDATE’S

PASSPORT

PHOTOGRAPH /

GAMBAR PASPORT

CALON

MEDICAL CHECK-UP FORM (for Malaysian Students)

HEALTH AND WELLNESS CENTRE INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

PART 1 / BAHAGIAN 1 ACADEMIC YEAR / TAHUN AKADEMIK PROGRAMME / PROGRAM SEMESTER

/ As in the Offer Letter / Seperti dalam Surat Tawaran

KULLIYYAH

MATRIC NO. / NO. MATRIK CONTACT NO. / NO. TELEFON

As in the Offer Letter / Seperti dalam Surat Tawaran

FULL NAME / NAMA PENUH

IDENTITY CARD / PASSPORT NO. / NO. KAD PENGENALAN / PASPORT AGE / UMUR

NATIONALITY / KEWARGANEGARAAN DATE OF BIRTH / TARIKH LAHIR

D D M M Y Y Y Y

MALE / LELAKI FEMALE / PEREMPUAN SINGLE / BUJANG MARRIED / BERKAHWIN

NAME OF GUARDIAN / NAMA PENJAGA

POSTAL ADDRESS OF GUARDIAN / ALAMAT PENJAGA

HOUSE TELEPHONE NO. / NO. TELEFON RUMAH OFFICE TELEPHONE NO. / NO. TELEFON PEJABAT

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PART 2 / BAHAGIAN 2 Please tick (/) in the relevant box / Sila tandakan (/) di kotak berkenaan

Declaration of self and immediate family (father, mother, siblings) illness. Explain in full if you or your family has

any of the following illnesses. / Pengakuan mengenai penyakit yang dihidapi sendiri dan ahli keluarga terdekat

(ibu, bapa, adik-beradik). Sila jelaskan dengan lanjut sekiranya anda atau ahli keluarga menghidapi penyakit-

penyakit berikut:

NO. MEDICAL PROBLEMS (Masalah Kesihatan)

SELF IMMEDIATE

FAMILY If Yes, please state

(Jika Ya, sila nyatakan) Yes No Yes No

1 Congenital or inherited disorder (Penyakit sejak lahir/ penyakit keturunan)

2 Allergy (Alergi)

3 Mental illness (Sakit jiwa)

4 Fits, stroke, other neurological disease (Sawan, strok dan lain-lain penyakit saraf)

5 Diabetes Mellitus (Kencing manis)

6 Hypertension (Darah tinggi)

7 Heart or vascular disease (Sakit jantung)

8 Asthma (Lelah)

9 Thyroid disease (Sakit tiroid)

10 Kidney disease (Sakit buah pinggang)

11 Cancer (Kanser)

12 Tuberculosis (Batuk kering)

13 Drug addiction (Penyalahgunaan dadah)

14 AIDS, HIV

15 Epilepsy (Gila babi)

16 Deformity (Kecacatan)

17 History of surgery (Sejarah pembedahan)

18 Other illnesses (Lain-lain penyakit)

I hereby certify that the information given above is true / Saya dengan ini mengaku segala maklumat kesihatan

yang diberi di atas adalah benar

………………………………………………………………….. …………………………………. Signature of candidate / Tandatangan calon Date / Tarikh

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PART 3 / BAHAGIAN 3 TO BE FILLED BY EXAMINING DOCTOR / UNTUK DIISI OLEH DOKTOR YANG MEMERIKSA

Tick as relevant / Tandakan yang berkaitan

1. GENERAL EXAMINATIONS / PEMERIKSAAN UMUM

HEIGHT / TINGGI cm/sm WEIGHT / BERAT kilogram

PULSE / NADI per minute / seminit BP / mmHg

a. PALLOR b. CYANOSIS c. OEDEMA

d. JAUNDICE e. LYMPH NODES f. SKIN

2. EXAMINATION OF EYE / RIGHT / LEFT / REMARKS / PEMERIKSAAN MATA KANAN KIRI CATATAN

a. UNAIDED VISION / PENGLIHATAN TANPA KACA MATA

__________________

b. AIDED VISION / PENGLIHATAN DENGAN KACA MATA

__________________

c. FUNDOSCOPY NORMAL

ABNORMAL __________________

d. COLOUR VISION / PENGLIHATAN WARNA

NORMAL

__________________ ABNORMAL

3.

EXAMINATION OF EAR / PEMERIKSAAN TELINGA

NORMAL

__________________ ABNORMAL

4.

ORAL CAVITY / RUANG MULUT

NORMAL

__________________ ABNORMAL

5.

HEART / JANTUNG

NORMAL

__________________ ABNORMAL

/

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6.

a. RESPIRATORY SYSTEM / SISTEM RESPIRATORI

NORMAL

__________________ ABNORMAL

b. * X-RAY NORMAL

__________________ ABNORMAL

* PLEASE ATTACH CHEST X-RAY AND REPORT (large film) / * LAMPIRKAN X-RAY DADA SERTA LAPORAN (filem besar) DATE OF X-RAY TAKEN / PLACE TAKEN / X-RAY REF. NO. TARIKH X-RAY DIAMBIL TEMPAT DIAMBIL NO. RUJUKAN X-RAY

D D M M Y Y

7.

ABDOMEN & HERNIAL ORIFICES / ABDOMEN & RONGGA HERNIA

NORMAL

__________________ ABNORMAL

8.

NERVOUS SYSTEM AND MENTAL CONDITION / SISTEM SARAF DAN MENTAL

NORMAL

__________________ ABNORMAL

9.

MUSCULOSKELETAL SYSTEM / SISTEM MUSKULOSKELETAL

NORMAL

__________________ ABNORMAL

10. OTHERS / LAIN-LAIN ________________________________________________________________

PART 4 / BAHAGIAN 4 11. EXAMINATION OF URINE / PEMERIKSAAN AIR KENCING Sugar / Gula _____________ Albumin ____________ Microscopy ____________

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PART 5 / BAHAGIAN 5 CERTIFICATION BY DOCTOR / PENGESAHAN DOKTOR Please tick (/) in the appropriate box / Sila tandakan (/) di alam kotak yang berkenaan I certify that on this day I have examined / Saya mengesahkan bahawa pada hari ini saya telah memeriksa

__________________________________________________I.C. No. / No. K.P. ________________________

and found that : / dan mendapati bahawa :

The above named is in good health / Beliau tidak menghidapi apa-apa penyakit dan disahkan sihat

The above named has / Beliau menghidapi ______________________________________________

The above named is undergoing treatment / Beliau sedang mendapat rawatan ________________

_________________________________________________________________________________

Signature of Doctor : _______________________ Date / Tarikh : ______________ Tandatangan Doktor Name of Doctor : _____________________________________________________________ Nama Doktor Qualification / Official stamp of hospital / clinic : Kelulusan dan Cop Rasmi Klinik: