Industrial Health Checkup

Date of Name of Contact No. of Name of

Sr.No. PHC Health Employee age Employee Company
Checkup
Health Checkup done by Company Report
Having any
Complaint of
(Cough/ Cold/ Sore Name of Doctor's
throat/ Fever/ Temprature SPO2 Doctor who Mobile No.
has checked
Breathlessness)

Industry/ Company Sign and Stamp

 Name of
responsible Contact No. of
Person for Responsible
person
Reporting