FORM No. 17
(Prescribed under Rule 14)
Health Register
1. Serial Number in the Register or adult worker
2. Name of Worker
3. Sex
4. Date of birth
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Medical Examination
and |
If declared unfit, unfit for work |
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Department/Works |
Name
of hazardous |
Dangerous
process |
Nature
of the job |
Raw
materials produce |
Date of posting |
Date
of leaving |
Reasons
for discharge/ |
Date |
Signed
and signs and sympioms observed |
Nature
of test and |
Result Fit/ Unfit |
Period
of temporary |
Reasons
for such |
Date
of declaring |
Date
of assign |
Signature
with |
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(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
(8) |
(9) |
(10) |
(11) |
(12) |
(13) |
(14) |
(15) |
(16) |
(17) |
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Note : 1. Separate page should be maintained for individually worker.
2. Fresh entry should be made for each examination.