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. 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.
Baseline (Original)
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.
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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