1969-HKRS30-8-59_Part06 — Page 32

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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

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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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