1964_FACTORIES_AND_INDUSTRIAL_UNDERTAKINGS_(CARCINOGENIC_SUBSTANCES)_REGULATIONS — Page 7

1986 Ed.]

Factories and Industrial Undertakings (Carcinogenic Substances) Regulations

[CAP. 59

AA 7

[Subsidiary]

Part 1

第1部

(to be filled by proprietor in the course of employment of the person)

(由東主在僱用該員期間內填妥)

Name of industrial undertaking:

工業經營名稱:

Address:

地 址:

Telephone:

電話號碼:

PARTICULARS OF EMPLOYED PERSON-

僱員個人資料

Name:

姓 名:

Sex:

性 別:

Date of birth:

出生日期:

Address:

地 址:

Telephone:

電話號碼:

Identity Card (or other identification document) No.:

身份證(或其他身份證明文件)號碼:

REGISTER OF 6-MONTHLY MEDICAL EXAMINATION-

每六個月進行一次身體檢查的紀錄-

Date of examination 檢查日期

Name of appointed medical practitioner 主診醫生姓名

Date urine sample provided 提供尿液樣本日期

PERIODS OF EMPLOYMENT IN CONNEXION WITH SUBSTANCES UNDER THE REGULATIONS--

與上述規例所管制物質有關的受僱期間 -

Name of Substance 物質名稱

Process 程序

From 由

To 至

I

Part 2

第2部

(to be filled and sent by proprietor on cessation of employment of the person)

(由東主在停止僱用該員時填報)