Form 16 Report

HEALTH REGISTER FORM - 16


Report From : To

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
Test Performed: