1964_FACTORIES_AND_INDUSTRIAL_UNDERTAKINGS_REGULATIONS — Page 16

A 16

[Subsidiary]

L.N. 132/69.

CAP. 59] Factories and Industrial Undertakings Regulations

[1985 Ed.

SECOND SCHEDULE

FORM 1

FACTORIES AND INDUSTRIAL UNDERTAKINGS REGULATIONS

[reg. 16B.]

REGISTER OF PERSONS EMPLOYED TO WORK UNDERGROUND IN INDUSTRIAL UNDERTAKINGS

1. Name of industrial undertaking:

2. Full name of person employed to work underground:

3. Residential address:

4. Identity Card No.:

5. Date of birth:

6.

7. Date on which worker first commenced to work underground in the undertaking:

Dates of medical examinations undergone by worker in accordance with regulation 16C(3):

(Full face photograph of worker).

(a)

(b)

(c)

FORM 2

[reg. 16C(3)]

FACTORIES AND INDUSTRIAL UNDERTAKINGS REGULATIONS

MEDICAL EXAMINATION REPORT

Part I. (To be completed in duplicate by the proprietor of the industrial undertaking).

To:

1. (Name of medical practitioner by whom examination is to be carried out)

I, (Full name of proprietor)

of (residential address of proprietor)

the proprietor of (name of industrial undertaking)

situated at (address of industrial undertaking)

request you to examine (full name of Employee/proposed Employee*)

in accordance with regulation 16C(3) of the Factories and Industrial Undertakings Regulations.