RITES PMPL JV

BMRCL PHASE 2 PROJECT

Format No.: RITES – PMPL JV/PHASE 2/SHE/0 /Rev: 00
PRE-MEDICAL CERTIFICATE FOR
GENERAL / CRITICAL WORKERS
(To be conducted by registered medical practitioner only)

I / we do hereby certify that we have examined Mr/Mrs.

________________________ S/o, W/o, D/o _____________________ candidate for
employment in the trade of ____________
Sub-contractor: -
On Examination

Height : _________Cm Weight : ________ Kg

Blood pressure : _________ Pulse : _____ / min
Vision : Hearing :
Examination if Myopia (near
sightedness) observed
Anaemia : Spine :
if Yes CBC test result to be referred (Adequately flexible for the job
concerned)
Mental Alertness & Stability: OK / Alcoholic : (occasional / Regular / Non-
NOT OK alcoholic)
(good eye, hand and foot co-ordination)
Others (Tobacco / Pan / Bhang) Physically challenged
Upper limbs: Lower limbs:
Adequate arm function and grip ( both Adequate leg and foot function
arms)
Blood group: ___________ If required: Complete Blood
Count:
Breathing:
Measure peak flow rate using standard peak Any other medical history
flow meter

For Critical Worker

 HEIGHT WORKER
History of Epilepsy/Convulsion : Yes / No If yes ECG is required:
Vertigo : Yes / No

 Drivers & Operators

Vision acuity Test :
Colour blindness test :
REMARKS
Defect in any ________________________________________.
 RITES PMPL JV
BMRCL PHASE 2 PROJECT
Format No.: RITES – PMPL JV/PHASE 2/SHE/0 /Rev: 00
PRE-MEDICAL CERTIFICATE FOR
GENERAL / CRITICAL WORKERS
(To be conducted by registered medical practitioner only)
I / we do not consider this as disqualification for the candidate for
employment as ________, his / her age is according to her/his statement _____
years and by appearances to be about _______ year's

He / She is Fit / Unfit for Employment

Date:

Signature of Candidate Signature and Designation of

Medical Examiner