Admission Booklet - International Islamic University Malaysia

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: [email protected]
IIUM website : http://www.iium.edu.my
WELCOME TO THE INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA
“THE GARDEN OF KNOWLEDGE AND VIRTUE”
1
Table of contents
No.
1.
Page
3
3.
Items
Welcoming Message from the Dean of the
Academic Management and Admission
Division
Terms and Conditions of Offer
and Registration
Mahallah Registration
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
2.
2
4-7
8
WELCOMING MESSAGE FROM THE DEAN OF THE
ACADEMIC MANAGEMENT AND ADMISSION DIVISION
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
3
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
Extension
Fax No.
2.
:
:
:
03 – 6196 4000
3990 / 4040 / 4047 / 4048
03 – 6196 4724
FEES AND CHARGES
Please refer to the following website for the details:
http://www2.iium.edu.my/finance/services/available-services-0
4
3.
REGISTRATION
For the purpose of registration, please bring along the following documents for verification
by the University authority :
CATEGORY
DOCUMENTS
STPM / STAM / i. On-line Offer Letter
ASASI
ii. Identity Card
(A/S/L/U/N/T) 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)
Diploma (E/F)
All Students
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
On-line Offer Letter
Identity Card
Birth Certificate
School Leaving Certificate
SPM/’O’ Level Certificate
STPM/STAM/ ’A’ Level/or equivalent ( if any)
Academic Transcript for Diploma Programme
MUET result (latest)
ORIGINAL OR
PHOTOCOPY
ORIGINAL
&
PHOTOCOPY
ORIGINAL
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.
5
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
6
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 Godfearing 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.
7
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
8
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,
hostel fees and book allowance.
tuition fee, related fee, monthly 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
9
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
10
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
11
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.
2.
3.
Group Personal Accident (GPA)
Group Term Takaful (GTT)
Group Medical Takaful (GMT)
12
F)
STUDENT ASSISTANTSHIP PROGRAM
 Students can obtain information pertaining to part-time employment in the campus
through advertisement at K/C/D/I

G)
Vacancies offered such as Administrative Assistant, Library Assistant, Graduate
Teaching Assistant, Graduate Research Assistant and Graduate Administrative
Assistant
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
13
WELCOMING NOTES FROM
THE CHAIRMAN OF “TA’ARUF WEEK”
‫السالم عليكن ورحمة ه‬
‫ّللا 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 Tshirts (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.
14
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.”
‫ﻮالسالم‬, “Garden of Knowledge & Virtue”
DR. AKMAL KHUZAIRY ABDUL RAHMAN
Dean
Student Affairs & Development Division cum
Chairman of “Ta’aruf Week”
International Islamic University Malaysia
15
CANDIDATE’S
PASSPORT
PHOTOGRAPH /
GAMBAR PASPORT
CALON
HEALTH AND WELLNESS CENTRE
INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA
MEDICAL CHECK-UP FORM
(for Malaysian Students)
(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
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
NATIONALITY / KEWARGANEGARAAN
AGE / UMUR
DATE OF BIRTH / TARIKH LAHIR
D
MALE / LELAKI
FEMALE / PEREMPUAN
SINGLE / BUJANG
D
M
M
Y
Y
Y
Y
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
1
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 penyakitpenyakit berikut:
MEDICAL PROBLEMS
(Masalah Kesihatan)
NO.
1
2
Congenital or inherited disorder
(Penyakit sejak lahir/ penyakit keturunan)
Allergy (Alergi)
3
Mental illness (Sakit jiwa)
4
5
Fits, stroke, other neurological disease
(Sawan, strok dan lain-lain penyakit saraf)
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)
SELF
Yes
No
IMMEDIATE
FAMILY
Yes
No
If Yes, please state
(Jika Ya, sila nyatakan)
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
2
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
PULSE / NADI
2.
BP
/
mmHg
b.
CYANOSIS
c.
OEDEMA
d.
JAUNDICE
e.
LYMPH NODES
f.
SKIN
EXAMINATION OF EYE /
PEMERIKSAAN MATA
c.
RIGHT /
KANAN
LEFT /
KIRI
REMARKS /
CATATAN
UNAIDED VISION /
PENGLIHATAN TANPA KACA MATA
__________________
AIDED VISION /
PENGLIHATAN DENGAN KACA MATA
__________________
NORMAL
ABNORMAL
__________________
NORMAL
ABNORMAL
__________________
EXAMINATION OF EAR /
PEMERIKSAAN TELINGA
NORMAL
ABNORMAL
__________________
ORAL CAVITY /
RUANG MULUT
NORMAL
ABNORMAL
__________________
HEART /
JANTUNG
NORMAL
ABNORMAL
__________________
d.
5.
per minute / seminit
kilogram
PALLOR
b.
4.
WEIGHT / BERAT
a.
a.
3.
cm/sm
FUNDOSCOPY
COLOUR VISION /
PENGLIHATAN WARNA
3
6.
a.
b.
RESPIRATORY SYSTEM /
SISTEM RESPIRATORI
NORMAL
ABNORMAL
__________________
* 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 /
TARIKH X-RAY DIAMBIL
D
7.
8.
9.
10.
D
M M Y
PLACE TAKEN /
TEMPAT DIAMBIL
X-RAY REF. NO.
NO. RUJUKAN X-RAY
Y
ABDOMEN & HERNIAL ORIFICES /
ABDOMEN & RONGGA HERNIA
NORMAL
ABNORMAL
NERVOUS SYSTEM AND MENTAL
CONDITION /
SISTEM SARAF DAN MENTAL
NORMAL
ABNORMAL
MUSCULOSKELETAL SYSTEM /
SISTEM MUSKULOSKELETAL
NORMAL
ABNORMAL
__________________
__________________
__________________
OTHERS / LAIN-LAIN ________________________________________________________________
PART 4 / BAHAGIAN 4
11.
EXAMINATION OF URINE / PEMERIKSAAN AIR KENCING
Sugar / Gula
_____________
Albumin ____________
Microscopy ____________
4
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 : _______________________
Tandatangan Doktor
Name of Doctor :
Nama Doktor
Date / Tarikh : ______________
_____________________________________________________________
Qualification / Official stamp of hospital / clinic :
Kelulusan dan Cop Rasmi Klinik:
5