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