FORM No. 43

(Prescribed under sub-rule (4) of rules 81G)

 Record of eye Examination

Sl.

No.

Department
works

Name of
worker

Sex

Age (on last
birth day)

Occupation

 

 

 

 

 

Nature

Date of
employment

(1)

(2)

(3)

(4)

(5)

(6)

(7)

 

 

 

 

 

 

 

 

 

 

 

Examination of eye sight

 

 

Date

Result

Signature of Ophthalmologist

Remarks

(8)

(9)

(10)

(11)

 

 

 

 

1. Inserted by S.R. No. 134/87 dated 17-1-1987 in K.G. No. 82 dated 27-1-1987