1973 Ed.]
1. I, ........
Factories and Industrial Undertakings Regulations
(full name of proprietor)
(residential address of proprietor)
[CAP. 59
A 27
the proprietor of
(name of industrial undertaking)
situated at
(address of industrial undertaking)
request you to examine
(full name of Employee/proposed Employee*)
in accordance with regulation 16C(3) of the Factories and Industrial Undertakings Regulations.
2. This Employee/proposed Employee* is/will be* employed to work
underground as a
(specify nature of Employee's/proposed Employee's* occupation)
and first commenced/will commence* such work on
(specify date or proposed date)
Date:
Signature of proprietor:
Part II. (To be completed in duplicate by the Employee or proposed
Employee).
A. Full Name of Employee/proposed Employee*
Date of Birth
Residential Address
B. History of Past Illnesses.
(a) Is there a history of pulmonary
tuberculoses?
If so give details
(b) Is there a history of other chronic
respiratory disease?
(Full face photo- graph of person examined).
(c) Is there a history of heart disease, diabetes mellitus or any other
serious or prolonged disease?
C. Present Complaints (if any).
I declare that to the best of my knowledge the answers given above
are accurate.
Date:
Signature of Employee/proposed Employee*:
[Subsidiary]