GMP Project, Sec-47, Gurgaon, HR, FORM XXXVI [ (see rule tll (c)] CERTIFICATE OF MEDICAL EXAMINATION 1. Certificate Serial No... Date. aan 2. Name Identification Marks a. ae (ii). 3, Father's Nam 4, Sex. wommenaiNvale / Female 5, Residence ~ Son / Daughter Of ...n.. 6., Date of Birth, if available «And / or Certificate age 7. Phisical Fitness | hereby certify that | have personally examined (name) Residing .. in building and construction work and that his / her age as lnearly as be ascertified from my examination is ....... years and that he / she is fit for employment in > The GMP Project, Gurgaon, Haryana as an adult / adolescent. ..son/ daughter of who Is desirous of being employed 8, Reason for (2) Refusal for certificate .. (2) Certificate being revoked lsignature / left hand thumb impression of building workers Medical inspector / Construction Medical officer} Signature with seal lExact details of phisical disability sould be clearly stated [Functional / productive abilities should also be stated if disability s statedGMP Project, Sec-47, Gurgaon, HR, ‘Sino Contractor : [Date | a) Name ) Identifications Marks b) Father's Name f) Sex c) Designation g) Date of Birth d) Address H/0_DM_ HTN 2) Any Previous Health Related Problem resulted from an accident b)_Any Critical Iliness ¢) Any Continuing Disease “d) Allergic to ‘e) Height Weight SINe Test Examination | Parameters Result / remat i) | General Physique ‘Normal ji) | Vision Estimated total Visual Performance using ‘Standard Orthorator like Timus Vision Testing. ii) [Hearing ‘Able to hear a forced whisper at Twenty four feet._| Yes 7No iv) Breathing Peak Flow rate using standard Peak Meter. ‘Adequate inadequate v)___| Upper Limbs ‘Arm functions and grip. ‘Adequate /inadequate vi) Spine Flexbilty. ‘Adequate /Inadequate vil) | LowerLimbs | Leg & Foot. ‘Adequate / inadequate vil) _ | General Mental alertness & Stability. ‘Adequate / inadequate i) Any other tests if the doctor considers necessary Signature of the Occupational Health Officer Name Date