MEDICAL FITNESS CERTIFICATE FOR EMPLOYEES

Part A
Certified that I Dr. -------------------------------- have examined Mr.
--------------------------Age ---------On (date) ---------------------- who has singed below in
my presence .General & Physical examination of Mr. ---------------------------------------do
not reveal any abnormality. He does not suffer from any acute / chronic skin disease or
any contagious like tetanus,typhoid, cholera or infectious disease. His eye site is
normal with/without glasses. In my opinion, Mr. --------------------------------------------- is
physically and mentally fit for working at heights.
Details of examination are given below:Parameters
Parameters
Yes
No
Height:

Epilepsy

Chest

Frequent headache

Weight

Height phobia

Vision

Limping gait

Hearing ability

Physical deformity

Pulse

Flat foot

Blood pressure

Mental depression

Any other information

Signature of Workman

Signature & rubber stamp of

Medical Practitioner with Reg No.

Part B
Safety Section
The applicant has appeared the following practical test conducted by Safety Dept (Strike
off whichever not applicable)
a) Walking freely over horizontal bar at 1 ft
: Pass / Fail
b) Wearing a safety belt and trying the rope knot
: Pass / Fail
c) Walking over a horizontal structure at 1.8 mtr. Height wearing a belt : Pass / Fail
d) General physique (OK/ Not OK)
: Pass / Fail
The above applicants performance in the above tests has been satisfactory /
unsatisfactory .So; I satisfied issue of this height pass to Shri
----------------------------------with Registration No ----------------------------------- in the
height pass register. This is valid for one year from the date of issue.
Date:

Seal with Signature

Safety Manager/ Engineer

To, The Medical Officer

Date:

APPLICATION FOR HEIGHT PASS

(To be filled by the individuals of company employees, sub contractor/PRW/Agency)
PartA
1. Applicant Name
: -------------------------------------------2. Occupation/designation
: -------------------------------------------3. Residential Address
: -------------------------------------------4. Age
: -------------------------------------------5. Sex
: -------------------------------------------6. Height
: -------------------------------------------7. Gate pass No.
: -------------------------------------------8. Name of the contractor / Agency
With whom engaged at present
: -------------------------------------------9. Description of present job
: -------------------------------------------10. Previous experience of working at height: ----------------------------------SL. No.

Name of Employer

Duration of Employment

Total Work
Experience

1.
2.
11. Is the applicant suffering from any of the following aliment (If yes detail to be given)
a) Blood Pressure -----------------b) Epilepsy ----------------c) Flat Foot -------------------d) Frequent head ace or reeling sensation------------------------------e) Mental depression -----------f) Limping gait ------------- h) Height Phobia---------------Part B
DECLARATION:
I hereby declare that the above information furnished by me is true and
correct. I shall always wear the safety belt and tie the lifeline whenever working at
unguarded heights of 2 meter and above. I shall not misuse the height pass issued to me
or transfer it to other person. I shall never come to duty or work at height / depth under
the influence of alcohol / drugs.
Date:
Name:
Sign:
(Applicant Name & Signature or L.T.I. (Left Thumb
Impression) In the case, he can not sign.
Note: In case the applicant is illiterate, an authorized person shall explain each point
/ item to the individual.
I certify that I am satisfied with the above certification of the
individual of the application of height pass and request for issue of height pass to him.
Name:
Sign & Date:
(Required only in case of Sub contractor/PRW/other Agency Employees )