FORM NO.

17
Prescribed under Rule 14
Health Register

1. Serial Number in the Register of adult worker
2. Name of Worker
3. Sex
4. Date of birth
Medical Examination and If declared unfit, unfit
the results thereof for work

D
e
p
a
r
t
m
e
n
t
/
w
o
r
k
s

N
a
m
e

o
f


h
a
z
a
r
d
o
u
s

p
r
o
c
e
s
s

D
a
n
g
e
r
o
u
s

p
r
o
c
e
s
s
/

o
p
e
r
a
t
i
o
n

N
a
t
u
r
e

o
f

j
o
b

o
r

o
c
c
u
p
a
t
i
o
n

R
a
w

m
a
t
e
r
i
a
l
s

p
r
o
d
u
c
e

o
r

b
y

p
r
o
d
u
c
t
s

l
i
k
e
l
y

D
a
t
e

o
f

p
o
s
t
i
n
g

D
a
t
e

o
f

l
e
a
v
i
n
g
/
t
r
a
n
s
f
e
r

t
o


o
t
h
e
r

w
o
r
k

R
e
a
s
o
n
s

f
o
r

d
i
s
c
h
a
r
g
e
/

l
e
a
v
i
n
g

t
r
a
n
s
f
e
r


D
a
t
e

S
i
g
n
s

a
n
d

s
y
m
p
t
o
m
s

o
b
s
e
r
v
e
d

N
a
t
u
r
e

o
f

t
e
s
t
s

a
n
d

r
e
s
u
l
t
s

R
e
s
u
l
t

F
i
t
/
U
n
f
i
t

P
e
r
i
o
d

o
f

t
e
m
p
o
r
a
r
y

w
i
t
h
d
r
a
w
a
l

f
r
o
m

t
h
a
t

w
o
r
k

R
e
a
s
o
n
s

f
o
r

s
u
c
h

w
i
t
h
d
r
a
w
a
l

D
a
t
e

o
f

d
e
c
l
a
r
i
n
g

h
i
m

u
n
f
i
t

D
a
t
e

o
f

a
s
s
u
i
n
g

f
i
t
n
e
s
s

c
e
r
t
i
f
i
c
a
t
e

S
i
g
n
a
t
u
r
e

w
i
t
h

D
a
t
e

o
f

t
h
e

F
a
c
t
o
r
y

M
e
d
i
c
a
l

O
f
f
i
c
e
r
/
t
h
e

c
e
r
t
i
f
y
i
n
g

S
u
r
g
e
o
n


(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

(13)

(14)

(15)

(16)

(17)

Notes: 1. Separate page should be maintained for individual worker
2. Fresh entry should be made for each examination

1. Subs, by Kerala Factories (Amendment) Rules, 2001, S.R.O No.1149/2001 dated 20-12-2001 in K.G.Ext. No.2073 dt. 28-12-2001.