Infectious Disease Prevention & Control Unit

Health Promotion and Disease Prevention Directorate

Form R1 – Application form for

Health Screening for renewal of Work Permit
*All investigations are to be carried out at a LOCAL PRIVATE CLINIC*

Who should fill this Health Screening for renewal of Work Permits Application Form?

1. Foreigners who were born or have lived for 6 months or more in a country reported as
very high-risk for tuberculosis

All foreigners who were born or have lived for 6 months or more in a country reported as
very high-risk for tuberculosis need to complete 1 Health Screening for Renewal of Work
Permits. The application form R1 needs to be completed one year after the first
application was made (a total of 2 years applying for health screening and working in
Malta) regardless of the job they have applied for. Applications need to be sent by the
employer to the Infectious Disease Prevention and Control Unit (IDCU) on
[email protected]

Confidential

Please read the following instructions carefully

As a potential employee, applicants have a duty to provide the relevant information to the Infectious
Disease Prevention and Control Unit (IDCU) within the Health Promotion and Disease Prevention
Directorate. All medical and sensitive personal information applicants provide, will be held in
complete confidence by the Directorate.

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31st May 2024 Superintendence of Public Health
Documentation

Application form should be duly filled by all parties and the requested health screening
investigations carried out and documented on the application. Any abnormal chest x-ray reports or
any health screening investigations that merit attention, need to be submitted with the application
form to IDCU on [email protected].

Kindly write ‘Renewal Form’ in the subject of the email.

You will receive approval via email.

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31st May 2024 Superintendence of Public Health
 Section A: PERSONAL INFORMATION
1. Details of Employee:

Name & Surname:

(As it appears on passport)

Nationality/ Citizenship:

Email:

Mobile:

Year when started working in Malta:

2. Details of Employer:

Name of Employer:

Name of company (if applicable):

Email:

Mobile/Telephone:

Job Reapplying for: ________________________________________________________

Detailed job description: _________________________________________________________

Renewal year with present employer: 1st renewal (2nd year working in Malta)

I hereby declare that the information given in this application is true to the best of my knowledge.

Signature of Employee Signature of Employer

Date: __________________ ID number: _________________

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31st May 2024 Superintendence of Public Health
 Section B: HEALTH SCREENING
Please note that it is MANDATORY that this section of the form is completed by ONE (1)
doctor only and the doctor’s contact telephone number and email address are clearly written
down.

Failure to comply with this will result in the application form NOT being processed.

1. Physical Examination

All employees need to be examined to exclude symptoms of scabies, food and water borne
illnesses (gastroenteritis) and vaccine preventable diseases such as chickenpox and measles.

I declare that the above-mentioned individual is not suffering from the above-mentioned
infectious diseases.
I declare that the above-mentioned individual is showing no symptoms suggestive of active
tuberculosis (prolonged cough for more than 2 weeks; Haemoptysis; Fever; Weakness;
Weight loss; Night sweats; Chest pain).

Important to state the dates when the CXR, vaccinations and health screening were taken. Otherwise, the
form will not be accepted

2. Chest X-Ray

To be done locally in the PRIVATE SECTOR

The Chest X-Ray needs to be taken within the last 6 weeks of submission of the renewal form.

A copy of the Chest X-Ray report must be attached with the application form.

Requirement Results submitted Date taken

(Tick as Applicable)

CHEST X-RAY
 CXR Normal
 CXR Abnormal

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 3. Hepatitis B Vaccination

 Full immunity against Hepatitis B is required amongst the following applicants prior to
renewal of work permit namely; Doctors, Dentists, Midwives, Nurses, Professions
Complementary to Medicine, Carers (including carers within Healthcare, Homes for
the Elderly, Institutions, etc), Beauty Therapists, Beauticians, Spa Therapists &
Massage Therapists and Tattooists.

 Hepatitis B antigen test (HBsAg) needs to be taken immediately prior to initiating Hepatitis
B vaccination schedule.

Results
Health Screening (Tick as applicable) Date taken

HEPATITIS B

1. Hepatitis B vaccination: Dosing schedule Date & Batch No.

 0 months
A. TWINRIX VACCINE  1 month
(Hepatitis A & B)  6 months

OR Dosing schedule Date & Batch No.

 0 months
B. ENGERIX  1 month
(Hepatitis B)
 6 months

OR

Date
2. Hepatitis B antibody -
(anti-HBs)*  anti-HBs greater than 10mIU/ml

 anti-HBs less than 10mIU/ml


Test to be taken only if
a. Hepatitis B vaccination record is unavailable, or
b. Hepatitis B vaccines were given more than 10 years from the date of application.
If anti-HBs is less than 10mIU/ml, applicant needs to start Hepatitis B vaccination schedule

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 4. Food Handlers

Applicants engaged in the preparation, manufacturing and treatment of a food business and who
handle or prepare food intended for human consumption (in terms of the Food Safety Act and
Subsidiary Legislation 449.27)

*Employees working as food handlers need to have taken the full course of
Hepatitis A and Typhoid vaccination prior to renewal*

Health Screening Results submitted Date

(Tick as applicable)

HEPATITIS A

Dosing schedule DATES & BATCH NO.

TWINRIX VACCINE
(Hepatitis A & B)  0 months

OR  1 month

 6 months

HAVRIX
0 months
(Hepatitis A)

6 months

OR
Date
3. Hepatitis A
antibody -  anti-HAs greater than 10mIU/ml
(anti-HAs)*
 anti-HAs less than 10mIU/ml

Test to be taken only if

a. Hepatitis A vaccination record is unavailable, or

b. Hepatitis A vaccines were given more than 10 years from the date of application.
If anti-HAs is less than 10mIU/ml, applicant needs to start Hepatitis A vaccination schedule

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 TYPHOID

DATE & BATCH NO.

TYPHIM VI  Vaccination record
(Valid for 3 years)

Important to state the dates when the vaccinations were taken. Otherwise, the form will not be accepted.

5. Polio and Diphtheria vaccinations

 Compulsory to all employees – on renewal doctor is to confirm that they have seen
proof of vaccination/immunity:

POLIO / DIPHTHERIA
Full immunity is required
DATE:
1. 1 dose administered in MALTA IPV Boostrix

Repevax (Sanofi)

Imovax BATCH/LOT NUMBER

Dultavax

Revaxis

OR
DATE:
2. Poliovirus and Diphtheria Immune
immunity test
Non-immune

Should blood level show no immunity, applicant must receive one dose of vaccine.

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31st May 2024 Superintendence of Public Health
 MEASLES

If on first time application applicant never received the vaccine, records were not provided or IgG result
was negative, two (2) doses of Measles vaccine needed to be administered

If 2 doses of the Measles vaccine were required, the second dose had to be taken as scheduled. If
not taken prior to renewal, the renewal application will not be approved.

Please indicate dates when vaccines were given and batch numbers below:

Vaccination (2 doses) DATE & BATCH NO.

2 doses required
Yes
No

Comments:

Section C: MEDICAL DOCTOR’S DETAILS

Doctor’s Name & Surname (in block letters): ____________________________________________

Medical Council Registration No:__________________

Stamp

Mobile No: ___________________________________

Email address: ________________________________

Signature: ___________________________________

The personal data requested is being processed according to Article 27 (a) (i) of the Public Health Act, the General Data Protection
Regulation (EU) 2016/679 and the Data Protection Act 2018.

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31st May 2024 Superintendence of Public Health