Project:

LIS OF IP MPLS Network for Indian Navy (VARUN)

Doc/Rev # STL-VARUN-EHS-M-F09-R0 Ver-1 EHS Manual-Annexure-F09 Medical Examination From

As Per Schedule VII

Periodicity of Medical Examination Of Building Workers [See Rules 81 (Iv) And 223 (A) (Iii)]
1. The employer shall arrange a medical examination of all the building workers employed as drivers, operators, of lifting
appliances and transport equipment before employing, after illness or injury, if it appears that the illness or injury might
have affected his fitness and, thereafter, once in every two years upto the age of forty and once in a year, thereafter.
2. Complete and confidential records of medical examination shall be maintained by the employer or the physician
authorised by the employer
S. Physical Senses & BP Breathing Limbs & Spine

Peak flow rate

No.

Average Peak
Blood Group

Upper Limbs

Lower Limbs

General
Flow rate
Pressure
Hearing
Weight

Height

Vision

Blood

Spine
Name of Person
Age

‘√’ Applicable box for OK and ‘X’ for not OK

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.
Note: In case if it is found that a person is in-capacitated, or suffering from transmittable skin disease or having some other
disorders which may cause hindrance in work, separate record to be generated providing details of deficiency.

Doctors Name: Signature:

Registration No.: Date:

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 Project:
LIS OF IP MPLS Network for Indian Navy (VARUN)

Doc/Rev # STL-VARUN-EHS-M-F09-R0 Ver-1 EHS Manual-Annexure-F09 Medical Examination From

FORM XI [SEE RULE 233(C)]

CERTIFICATE OF MEDICAL EXAMINATION

1. Certificate Serial No. …………….. Date………………..

2. Name……..………….. Identification marks: (1) ..……………….. (2) ………………….
3. Father‘s Name………………
4. Sex…………..
5. Residence …………………… son/daughter of…………………
6. Date of birth, if available……………… and / or certificate age…………………
7. 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 is…………….year 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 impression of building workers

Signature with Seal 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.

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