Proforma for Screening Workmen

Engaged by Contractors / Sub-Contractors

Name of the Contractor / Sub-contractor: ___________________________________________
Photo Full Name of the workman _______________________________________________________
Father / Husband’s Name: _______________________________________________________
Permanent Home Address: _______________________________________________________
_________________________________________________________________________
Present Address: ________________________________________________________________
__________________________________________________________________________________________
Gender: Male / Female PF No / UAN No: __________________________ESI No: ______________________
* Date of Birth ________________ (DD-MM-YYYY) Age ____ years Mobile Number ____________________
(Please obtain photocopy of birth Certificate issued either by School or Gram Panchayat as required under Workmen’s Compensation Act. 1923.)
(For existing Members Insist on photocopy of UAN & ESI Cards)

KYC Details: (Please obtain photocopy of KYC Document for other than Aadhaar)
# Aadhaar Number _______________________________________
Other KYC Documents
Code P T D E N R
Type Permanent Passport No / Driving License Voters ID National Ration Card
Account Validity Date No Population
Number(PAN) # Register

Number
Date
Married / Single / Widow / Widower _______________Number of Children________________
Mother Tongue _________________Other Languages Known____________________________
In case of emergency person to be contacted __________________ _ __ (With address and Telephone
Number if any) _________________________________________________________________________

# Bank Account Details (Please collect the photocopy of Passport & Cancelled Cheque leaf)
Name of the Bank Branch Branch Address SB Acct No. IFSC Code

# Education
Examination Passed Year School / Board

*Collect one of the 16 documents approved by Govt. of India as valid proof of age
I certify that above particulars are true and I also hereby give my consent to L&T to obtain my details to do eKYC with UIDAI database.
# Mandatory Details and Documents

Signature / Thumb Impression: ___________________________

PREVIOUS WORK EXPERIENCE

Name of the Contractor Period

Sl. No. Project Site Category Salary / Wage Rate
Organization From To

1.
2.
3.

Signature of Subcontractor with Seal

MEDICAL FITNESS
Designation / Trade of the workman __________________________________________________________
Any other identification mark:
Weight: _________ Height: _______ Vision: _________________ Chronic Illness if any______________
** Medical Fitness (Please put tick in appropriate box)
Fit Unfit
** Due Date for periodical medical examination
(Applicable only for special trades)
Medical Certificate serial No. _______________________
(Certificate to be enclosed along with this form)
________________________________________________
(Seal & Signature of Regd. Medical Practitioner)
Referred by / References
Screened by me. Certificates / Details Verified / Not Verified.
Referred to Mr. _______________________________________ for _______________________ on the job trail.

Site-In-Charge / Section-In-Charge / Site Engineer Date & Time:

TRIAL REPORT (Fit / Not Fit)
Name and Signature of Trail Officer
Seen and briefed the EHS rules of the site. Induction Reference # ______________________________________

EHS Manager / Officer Date & Time:

Recommended for Job Work with M/s. _____________________Project Site _____________________________

Construction Manager / Section-In-Charge

Employment Card / Gate Pass (Ref # ____________) issued and details entered into Register of workmen.
eKYC Performed Yes No Matches filled details Yes No
Time Keeper _________________________________ Date & Time:
** Ref. Certificate of medical examination for various trades of workmen.
 FORM- XI.
[See rule 223(c)]
Certificate of medical Examination

1. Certificate Serial No…………………

Date…………………….
Date ……………………
2. Name …………………………………………………………………………………

Identification marks: 1………………………………………………

2.………………………………………………..

3. Fathers name ………………………………………

4. Sex ………………………………………………...
5. Residence ………………………....Son/ Daughter/ Wife of Shri…….…………………………
6. Date of birth, if available……………………………......... Certificate age ………………
Physical fitness...................................…………………………………………………………………
……………………………………………………………………………………………………
I hereby certify that I have personally examined (name) ……..…………………………..
Son/daughter/Wife of………………………………….residing at……………….................……
who is desirous of being employed in building and construction work and that his/ her age as
nearly as can be ascertained from my examination …..……… Years and that he/ she is fit for
employment in …..… as an adult/ adolescent.
8. Reason for
1. Refusal of certificate………………………....................................................................
……………………………………………………………………………………………...…
2. Certificate being revoked…………………………………………………………..............
…………………………………………………………………………………………….…..

Signature/ Left hand thumb Signature with seal

Impression of building worker Medical Inspector/C.M.O.

Note: -1. Exact details of cause of physical disability should be clearly stated.
2. Functional/ productive abilities should also be stated if disability is stated
 Electrician Competency Certificate Photo
Project: -
Location/City: -
Sub-Contractor:-
Location Date
Name Designation
Date of birth ID card no.
Validity of ID
Total work Exp.
card

Date of Joining Certificate issued on Certificate Issued by

Points to check to skill Test procedure Max Marks

Marks Obtain
Formal interview about his past working experience and 2
knowledge in electrical field.
Capable to work with live electrical on Single phase line by 3
using 11KV rated hand gloves.
Capable to work with live electrical on three phase line by 3
using 11KV rated hand gloves.
Capable to work with portable power tool i.e. Drill machine 2
and other tools and tackle i.e. Screw driver, Nose Plier, Cutters
Total Marks 10

Whether person is certified to work with electrical Smart meter

installation Unfit
Fit

Nature of work

Competency test Conducted by:

Department S/c Representative Site Engineer/City In charge
Name
Signature with seal
for S/c
Date

Sensitivity: LNT Construction Internal Use