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(nenilenendad adoreas of proprietors
the proprietor of
situated at
request you to examine
Crane af fralistetat undersøking)
Gooddress og fruennial undertakingl
Qal name of Kimploree/proposed Employeet)
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
Capretty mature of Employer's) proposed. Employeér occupo M and first commenced/will commence such work on
Cepwell date or proposed dante)
Date: Alastorpioneeresejemo
Signature of proprietor:
SELENJEPANG
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 monenserecciandoppe
B. History of Past filnesses.
(4) Is there a history of pulmonary
tuberculoses?
If so give details
11
Part II. (To ba completed in duplicate by examining medical practitioner).
A. General Nutrition
Weight
lbs. Height
Eart
Eyes: Visual acuity R............ La Cardiovascular System Pulse rate................... B.P,
JAANIKANI+T.
Abdomen
Hernias
Genito-urinary System
Urine .........ni 5p. G.
Alb.
Sugar
Skeletal System
Upper Lumby
Lower lumbs
Nervous System
B. Chest X-ray Examination (dato
(nopea kaset praecllioner bo whom X-ray accoum Crudylony de mader
Dr.
follows:
)
reports as
CAMANAKAKA++
(8) Is there a history of other chronic
respiratory diseas07
(Full face photo- graph of person examined).
(e) Is there a history of heart disease, disbetes 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 Employer/proposed Employee*:
C. I have examined the above named
Gulf nutrise)
in accordance with this report, and consider that he is Bl/unft* to work underground in an industrial undertaking to which Part IJA of the Factories and Industrial Undertakings Regulations applice.
Date:
Signature of Examining Medical Practitioner:
Name of Examining Afedical Practitioner:
Address:
Telephone Number:
Oblock capinara)
Mareks (4) Các cópy of this completed form abould be sent by the cranialog medical pracdcionet under cooüdenuat cover to the wealny inthetrial health offer. Indus urist Health Division, Taboor Department. The other copy is to be reudoed by (be examinina ruedical practitioner.
(8)
* Debte bioberer = mappientis.
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