1

Department Works

2
3. Sex :
Name of Hazardous process

3
Dangerous process/operation

4. Date of birth :

4
Nature of job or occupation 2. Name of Worker :
of adult Workers :

5
By-products likely to be exposed toRaw materials, products or

6
1. Serial Number in the Register

Date of posting

7
Date of leaving/transfer to or transfer

8
Discharge/ leaving or transferReasons for

9
Date

10
Observed during examinationSigns and symptoms

11
FORM NO. 32

Health Register

& results thereofNature of tests

Results therefore

2. Fresh entry should be made for each examination.

12
Medical examination

Result Fit/Unfit

Note : 1. Separate page should be maintained for individual worker.

13
Withdrawal from that workPeriod of temporary
(Prescribed under Rule 68-T and 102)

work

14
Reasons for such withdrawal

15
Unfit for that workDate of declaring him

16
If declared unfit for

Date of issuing fitness Certificate

17
Medical Officer/ the Certifying Surgeon.Signature with date of the factory