1964_FACTORIES_AND_INDUSTRIAL_UNDERTAKINGS_REGULATIONS — Page 17

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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.

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1985 Ed.]Factories and Industrial Undertakings Regulations[CAP. 59A 17[Subsidiary]This Employee/proposed Employee* is/will be* employed to work underground2.as a* (specify nature of Employee's/proposed Employee's occupation)and first commenced/will commence* such work onDate:(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 BirthResidential AddressB. History of Past Illnesses.(a) Is there a history of pulmonary tuberculosis?If so give details(b) Is there a history of other chronicrespiratory disease?(Full face photograph of person examined).(c) Is there a history of heart disease, diabetes mellitus or any otherserious 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 NutritionWeightkg HeightmmEyes: Visual acuity R.L.Cardiovascular System Pulse rateEarsB.P.L.N. 238/84.
Baseline (Original)
1985 Ed.]Factories and Industrial Undertakings Regulations[CAP. 59A 17[Subsidiary]This Employee/proposed Employee* is/will be* employed to work underground2.as a* (specify nature of Employee's/proposed Employee's occupation)and first commenced/will commence* such work onDate:(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 BirthResidential AddressB. History of Past Illnesses.(a) Is there a history of pulmonary tuber-culoses?If so give details(b) Is there a history of other chronicrespiratory disease?(Full face photo- graph of person examined).(c) Is there a history of heart disease, diabetes mellitus or any otherserious 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 NutritionWeightkg HeightmmEyes: Visual acuity R.L.Cardiovascular System Pulse rateEarsB.P.L.N. 238/84.
2026-05-04 17:30:49 · Baseline
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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 tuber-

culoses?

If so give details

(b) Is there a history of other chronic

respiratory disease?

(Full face photo- graph 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.

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