A 28
CAP. 59]
Factories and Industrial Undertakings Regulations
[1973 Ed.
[Subsidiary]
Part III. (To be completed in duplicate by examining medical practitioner).
A. General Nutrition
Weight
lbs. Height
ins.
Eyes: Visual acuity R.
Cardiovascular System Pulse rate
L.
Ears
B.P.
Abdomen
Hernias
Genito-urinary System
Urine
Sp. G. ............ Alb.
..... Sugar ...
Skeletal System
Upper limbs
Lower limbs
Nervous System
.)
reports as
B.
Chest X-ray Examination (date
Dr.
(medical practitioner by whom X-ray examination is made)
follows:
C. I have examined the above named
(full name)
in accordance with this report, and consider that he is fit/unfit* to work underground in an industrial undertaking to which Part IIA of the Factories and Industrial Undertakings Regulations applies.
Date:
Signature of Examining Medical Practitioner:
Name of Examining Medical Practitioner:
Address:
(block capitals)
Telephone Number:
Notes: (a) One copy of this completed form should be sent by the examining medical practi- tioner under confidential cover to the senior industrial health officer, Industrial Health Division, Labour Department. The other copy is to be retained by the examining medical practitioner.
(b) * Delete whichever is inapplicable.