1

Sl. No

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Department/Works

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Name of Worker
Name of the Factory :

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Sex

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Age (at last birth day)

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workDate of employment on present

Date of leaving or transfer to other

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transfer
work-with reasons for discharge or
1

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Nature of job or occupation

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likely to be exposed toRaw materials products or by-products
[FORM No. 16

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Dates
HEALTH REGISTER

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Unit
Fit or
Dates of medical
examination and
the results thereof
Results

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Signs and symptoms observed during examination

Address :

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Nature of tests and results thereof

If declared unfit for work, state period of suspension with

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reasons in detail
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Whether certificate of unfitness issued to the worker

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Re-certified fit to resume duty on

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Signature of the Certifying Surgeon with date