Place: SUTRAPADA	Signature of examining authority
Date:	Name and designation in block letter:

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* Delete whatever is not applicable

**One copy of the certificate shall be handed over to the person concerned and another copy shall be send to the manager of the mine concerned by registered post; and the third copy shall be retained by the examining authority.

Report of The Examining Authority
(To be filled in for every medical examination whether initial or periodical or re -examination or after cure/control of disability).
Annexure to	as result of medical examination on
Identification Mark:
1.General Development:	Left Thumb Impression of the Candidate
2.Height: cms
3.Weight: kgs
4. Eyes: (i) Visual Activity-Distant Vision (with or without glasses,)
Right Eye:	Left Eye:
(ii) Any Organic Disease Of Eyes:	(iii) Night Blindness:
(iv) Colour Blindness:	(v) Squint:
5. Ears: (i) Hearing:
Right Ear:	Left Ear:
(ii) Any Organic Diseases:
6. Respiratory System:
(i) After Full Inspiration: cms	(ii) After Full Expiration: cms
7. Circulatory System:
Blood Pressure: mm/Hg	Pulse: /Min
8. Abdomen:
Tenderness:	Liver:
Speen:	Tumour:
9. Nervous System:
History Of Fits or Epilepsy:	Paralysis:
Mental Health:
10. Locomotory System:
11. Skin:
12. Hydrocele:
13. Hernia:
14. Any Other Abnormality:
15. Urine: Reaction:
Albumin:	Sugar:
16. Skiagram Of Chest:
17. Any other test considered necessary by the examining authority.
18. Any opinion of specialist considered necessary.
PLACE: GHCL LTD SUTRAPADA	Signature of the examining authority
NAME:	DESIGNATION :
CITY / TOWN :	DISTRICT :
PH / MOB:	EMAIL ADDRESS:
PLACE OF POSTING :	PO. : SUTRAPADA  STATE:

Report of medical examination under mines rule 29-B

(To be issued in continuation with Form O)

Name:

Identifiction Mark:

Result of Lung Function Test (Spirometry)

Parameters	Predicted Value	Performed Value	% Of Predicted
Forced Vital Capacity (FEV)
Forced Vital Capacity FEV1
FEV1/FVC
Peak expiratory flow

Spirometry Report Enclosed

Signature of examination authority

Report of Medical Examination as per the recommendations of National Safety Conferences in Mines

(To be issued in continuation with Form O)

Name:

Identifiction Mark:

1. Cardiological Assessment

Ausculation	S1
	S2
	Additional Sould
Electrocardiogram (12 leads) findings:

Enclosed ECG

2. Neurological assessment

Findings	Normal/abnormal
Superficial reflexes
Deep Reflexes
Peripheral Circulation
Vibrational Syndromes

3. ILO Classification Of Chest Rediograph:

Profusion Of Pneumoconiotic Opacities	Grades	Types

Enclosed chest radiograph

4. Audiometry Findings

Conduction type	Left Ear	Right Ear
Air Conduction
Bone Conduction

Enclosed audiometry report

5. Pathological/Microbiological Investigations

S.No.	Tests	Findings
1.	Blood-TLC,DLC,Hb,ESR,Platelets
2.	Blood sugar - fasting & P.P.
3.	Lipid profile
4.	Blood Urea,Creatinine
5.	Urine routine
6.	Stool routine

Enclosed investigation report

6. Special Test For Mn exposure

Behavioural Disturbances	Present/Not present
Neurological Disturbances	Speech Defect
	Tremor
	Adiadocskinesia
	Emotional Changes

Enclosed report

7. Any Other Special Tests Required :

Signature of examination authority