* Name of the Factory :

+ , . / 0 1 2 *3 (it or )nit ** *+ *, **. */ *0 transfer Sex Age (at last birth day) Date of employment on present work Date of leaving or transfer to other work with reasons for dis!harge or Nat"re of #ob or o!!"pation Dates $es"lts Name of Worker likely to be exposed to$aw materials prod"!ts or by prod"!ts Dates of medi!al examination and the res"lts thereof Signs and symptoms observed d"ring examination Nat"re of tests and res"lts thereof %f de!lared "nfit for work& state period of s"spension with reasons in detail Whether !ertifi!ate of "nfitness iss"ed to the worker $e !ertified fit to res"me d"ty on Signat"re of the 'ertifying S"rgeon with date Department/Works

Sl. No

[FORM No. 16

HEALTH REGISTER Address :