FORM No. 29

(Prescribed under Rule 81 A)

 Certificate of fitness for employment in hazardous processes and operations

(To be issued by Factory Medical Officer)

1.       Serial Number in the register of adult workers         :

2.       Name of person examined                            :

3.       Father’s Name                                             :

4.       Sex                                                              :

5.       Residence                                                    :

6.       Date of birth, if available                               :

7.       Name and address of the factory                            :

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 ………………. and who is desirous of being employed in above mentioned process/operation and that his/her age, as nearly as can be ascertained from my examination, is …………………….. years.

          In my opinion he/she is fit for employment in the said manufacturing process/operation.

          In my opinion he/shed is fit for employment in the said manufacturing process/operation for the reasons ……….……….……….……….……….…
……….……….……….……….……….……….……….……….…….……….

          He/She is referred for further examination to the Certifying Surgeon.

          The serial number of the previous certificate is …………….……….……
……….……….……….……….……….……….……….……….……….……

 

Signature of left hand                                                  Signature of the
thumb impression of                                                   factory Medical
person examined :                                                       Officer

 Stamp of Factory Medical Officer
with name of the Factory:

                                                                                                     

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

 

  

 

 

 

 

 Note :-    1.  If declared unfit, reference should be made immediately to the Certifying Surgeon

              2.  Certifying Surgeon should communicate his findings to the occupier within 30 days of the receipt of this reference.