1973 Ed.] Factories and Industrial Undertakings
[CAP. 59
A 29
Regulations
[Subsidiary]
FORM 3
[reg. 16C(4).]
To:
FACTORIES AND INDUSTRIAL UNDERTAKINGS REGULATIONS
CERTIFICATE AS TO FITNESS OF EMPLOYEE/PROPOSED
EMPLOYEE*
(proprietor of industrial undertaking)
(address of industrial undertaking)
I hereby certify that Mr.
(full name)
of
(residential address)
has been examined medically in accordance with regulation 16C(3) of the Factories and Industrial Undertakings Regulations and is fit/unfit* to work underground in an industrial undertaking to which Part IIA of the regulations applies.
Date of issue:
Signed:
Note:
* Delete whichever is inapplicable.
(senior industrial health officer)