1985 Ed.]
Factories and Industrial Undertakings Regulations
[CAP. 59
A 17
[Subsidiary]
This Employee/proposed Employee* is/will be* employed to work underground
2.
as a
* (specify nature of Employee's/proposed Employee's occupation)
and first commenced/will commence* such work on
Date:
(specify date or proposed 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 tuberculosis?
If so give details
(b) Is there a history of other chronic
respiratory disease?
(Full face photograph 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*:
Part III. (To be completed in duplicate by examining medical practitioner).
A. General Nutrition
Weight
kg Height
mm
Eyes: Visual acuity R.
L.
Cardiovascular System Pulse rate
Ears
B.P.
L.N. 238/84.