Form 27
(Prescribed under Rule 122)
Certificate of fitness for employment in hazardous processes/dangerous operations
(To be issued by Certifying Surgeon)
1. Serial Number in the register of adult workers :
2. Name of person examined :
3. Fathers Name :
4. Sex :
5. Residence :
6. Date of birth, if available :
7. Referred by-
(a) Name and address of the factory :
(b) Name of the manager :
8. The worker is proposed to the employed in-
(a) Hazardous process :
(b) Dangerous operation :
I certify that I have personally examined the above named person whose identification marks are . Who is desirous of being employed in above mentioned process/operation and that his/her age, as nearly as and can be ascertained form by examination, is .. years and in any opinion is fit/unfit for employments in the said process/ operation.
He/She is fit to be employed and may be employed in some other nonhazardous operation such as .
He/She may be produced for further examination
after a period of
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He/She is advised following further examination . . . .
He/She is advised following treatment . . . . .
The Serial No. of the previous certificate is
Signature or left hand thumb
Impression of person examined:
Signature
Certifying Surgeon:
Date :
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I certify that I examined the person mentioned above on (date of examination) |
I extent this certificate unit (If certificate is not extended, the period for which the worker is considered unfit for worker is to be mentioned |
Signs and symptoms observed during examination |
Signature of the certifying Surgeon |
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Notes :- To be issued by the Certifying Surgeon and a copy to be maintained in a bound book or in a file.