1964_FACTORIES_AND_INDUSTRIAL_UNDERTAKINGS_REGULATIONS — Page 18

A 18

[Subsidiary]

L.N. 248/82.

CAP. 59] Factories and Industrial Undertakings

Abdomen

Hernias

Genito-urinary System

Urine

Upper limbs

Skeletal System

Regulations

Sp.G.

Alb.

Sugar

Lower limbs

Nervous System

B. Chest X-ray Examination (date

[1985 Ed.

Dr.

reports as

(medical practitioner by whom X-ray examination is made)

follows:

C. I have examined the above named

(full name)

in accordance with this report, and consider that he is fit/unfit* to work underground in an industrial undertaking to which Part IIA of the Factories and Industrial Undertakings Regulations applies.

Date:

Signature of Examining Medical Practitioner,

Name of Examining Medical Practitioner.

Address:

(block capitals)

Telephone Number:

Notes: (a) One copy of this completed form should be sent by the examining medical practitioner under confidential cover to the senior occupational health officer, Occupational Health Division, Labour Department. The other copy is to be retained by the examining medical practitioner. (b) * Delete whichever is inapplicable

FORM 3

[reg. 16C(4)]

To:

FACTORIES AND INDUSTRIAL UNDERTAKINGS REGULATIONS

CERTIFICATE AS TO FITNESS OF EMPLOYEE, PROPOSED

EMPLOYEE*

A proprietor of industrial undertaking)

(address of industrial undertaking)

I hereby certify that Mr.

(full name)

of

(residential address)

has been examined medically in accordance with regulation 16C(3) of the Factories and Industrial Undertakings Regulations and is fit/unfit* to work underground in an industrial undertaking to which Part IIA of the regulations applies.

Date of issue: Signed:

L.N. 248/82.

(senior occupational health officer)

Note:

* Delete whichever is inapplicable.