Sl No
|
Department
|
Emp Code
|
Name of Worker
|
Sex
|
Age (At Last Birth day)
|
Date of Employment on present Work
|
Date of Leaving or transfer to other work with reasons for discharge or transfer
|
Nature of Job or Occupation
|
Raw Materials or by products likely to be exposed to
|
Dates of Medical Examination and results thereof
|
Result - Fit/Unfit
|
Signs and symptom observed during Examination
|
Nature of Tests and Results
|
If declared unfit for work, state period of suspension with reasons in detaial
|
Whether certificate of Unfitness issued to the Worker
|
Recertified fit to resume duty on
|
Signature of the Certifying Surgeon with Date
|