• inner-page-banner

Form No.17

Home/ Forms/ Form No.17

(PRESCRIBED UNDER RULE 14)

 

HEALTH REGISTER (In respect of persons employed in occupations declared to be dangerous operations under Section 87)

Name of Certifying Surgeon :

(a)Shri ............                .              From .........                              To...........

(b)Shri ............                               From .......                                 o...........

(c)Shri ............                               From ........                               To...........

Serial No. Work No. Name of Worker Sex Age (last birthday) Date of employment on present work Date of leaving or transfer to other work Reason for leaving transfer or discharge Nature of Job or occupation Raw material or By product handled
Dates of medical Examination by Certifying Surgeon
                   
Result of Medical Examination

 

If suspended from work, state period of suspension with detailed reasons. Recertified fit to resume duty on (with signature of Certifying Surgeon) If certifying of unfitness or suspension issued t o worker Signature with date of Certifying Surgeon
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
             
Top