Form IX

(For mine employees only)

[See rule 109, rule 113(1) , rule 119(1) and rule 142]

Report of medical examination

(To be issued in triplicate)

Certificate No…………..

Certified that Shri/ Smt. /Miss………… employed as ………. in ………mine, Employee number……… . has been examined for an

Initial/Periodical Medical Examination. Employee appears to be………… years of age. The findings of the examining authority are given in the

attached sheet. It is considered that Shri/Smt. /Miss…………..

(a) is medically fit for any employment in mines.

(b) is suffering from…………. and is medically unfit for

(i) any employment in mine; or

(ii) any employment below ground; or

(iii) any employment or work……….

(c ) Employee is suffering from………… and should get the disease/disability cured/controlled and be re-examined within a period of

………..months. Employee shall appear for re-examination with the result of the test of………… and the opinion of the …………Specialist

from………… Employee may be permitted/not permitted to carry on their duties during this period.

Space for affixing Passport

Size Photograph of the

Candidate.

Place : Signature & name of the examining authority

With date and seal

Report of the examining authority

(to be filled in for every medical examination whether initial or periodical or re-examination or after cure/control of disability).

Annexure to Certificate No…………as result of medical examination on …….

Identification Mark……………..

Left thumb impression and Signature of The candidate

1. General development- Good/Fair/Poor

2. Height…………Cms.

3. Weight…………kg.

4. Eyes :

(i) Visual acuity-Distant vision (with or without glasses): Right eye……..Left eye…………..

(ii) any organic disease of eyes

(iii) night blindness

(iv) Color blindness (to be tested in IME )

(v)Squint

5. Ears :

(i) Hearing: right ear………….Left ear ……………..

(ii) Any organic diseases.

(iii) Audiometry Findings :

Conduction Type Left Ear Right Ear

Ear Conduction Normal/Abnormal Normal/Abnormal

Bone Conduction Normal/Abnormal Normal/Abnormal

Enclosed Audiometry Report.

6. Respiratory system.

Auscultatory Finding:

Chest measurement :

(i) after full inspiration …………cms.

(ii) after full expiration…………..cms.

Result of Lung Function Test (Spirometry)

Parameters Predicted Performed Value % of Predicted

Value

Forced Vital Capacity (FVC)

Forced Vital Capacity 1 FEV1

FEV1/FVC

Peak Expiratory Flow

Enclose Spirometry Report

7. Circulatory system:

Blood Pressure

Pulse

Cardiological Assessment

Auscultation S1

S2

Additional Sound

Electrocardiograph (12 leads) findings : Normal/Abnormal

Echocardiography finding (to be tested in IME) Normal/Abnormal

Enclose ECG

Enclose Echocardiography report

8. Abdomen :

Tenderness.

Liver.

Spleen.

Tumour.

Ultrasonography of Whole Abdomen (to be tested in IME )

(Enclose Ultrasonography report)

9. Nervous system:

History of fits or epilepsy

Paralysis.

Mental health.

Neurological Assessment

Findings Normal/Abnormal

Superficial Reflexes

Deep Reflexes

Peripheral Circulation

Vibrational Syndromes

Special Tests for Manganese exposure

Behavioral Disturbances Present/Not Present

Speech Defect Present/Not Present

Neurological Disturbances Tremor Present/Not Present

Adiadocokinesia Present/Not Present

Emotional Changes Present/Not Present

10. Locomotory system

11. Skin.

12. Hydrocele.

13. Hernia.

14. Teeth

15. Speech

16. Pathological Investigations:

S.No. Tests Findings

1 Blood-Tc,Dc,Hb,ESR, Platelets WNL/Abnormal

2 Blood Sugar- Fasting & PP WNL/Abnormal

3 HbA1c(to be tested in IME and for diabetic person WNL/Abnormal

during PME )

4 Lipid profile WNL/Abnormal

5 Blood Urea, Creatinine WNL/Abnormal

6 Urine (Reaction, Albumin, Sugar) WNL/Abnormal

7 Stool Routine WNL/Abnormal

8 Sputum test for AFB(For Food handling employee)

9. Hemoglobin Electrophoresis for sickle cell disease /trait WNL/Abnormal

(to be tested in IME )

10. Bilirubin WNL/Abnormal

11. SGOT WNL/Abnormal

12. SGPT WNL/Abnormal

13. delta aminolevulinic acid in urine ( for person exposed to WNL/Abnormal

Lead)

Enclose all Investigation Reports.

17. Skiagram of chest.

ILO Classification of Chest Radiograph :

Profusion of Pneumoconiotic Grades Types

opacities

Present/Absent

Enclose Chest Radiograph

18.Any other abnormality.

19. Any other test considered necessary by the examining authority.

20. Any opinion of specialist considered necessary.

Place: Signature & name of the examining authority

With date and seal

Medical Standard of Fitness for Persons to be employed in Mines (Initial Medical Examination).

1. The person shall be in good physical and mental health and free from any physical defect, likely to interfere with efficient employment in

mines.

2. Speech must be without serious impediment.

3. Teeth shall be in good condition and where necessary, the employee shall be provided with dentures for effective mastication (well filled

teeth shall be considered as sound). The gums shall be in healthy condition.

4. Skin: - There shall be no evidence of extensive and chronic skin disease or ulceration. In the case of an infective type of skin disease, the

candidate may be declared fit after undergoing a treatment.

5. Hearing in each ear shall be good and there shall be no sign of disease of the ear. Audiometric examination shall be normal and the person

shall be free from deafness in each ear.

6. Distant vision of eye with or without glass should not be less than following standard :

a) For underground workers

Better eye 6/6

Worse eye 6/9

b) For surface/opencast workers

Better eye 6/9

Worse eye 6/12

c) Intra-ocular lens implant: In the case of a person who has undergone intraocular lens implant, if the visual activity with intra-ocular lens

is according to the standards laid down, the person concerned may be considered fit

d) Fundus examination: In myopia -2Diopter or more, Fundus examination should be carried out and the results recorded. In the event of

pathological condition being present, which is likely to be progressive and affect the efficiency of the candidate, he shall be declared

unfit.

e) Color vision: - The testing of color vision is compulsory and the results should be normal. The Ishihara's Plates shall be used for testing

color vision.

f) There should be no night blindness for persons employed below ground and for persons employed in open cast working in shifts other

than in morning’s shifts.

g) Any organic disease or a progressive refractive error which is likely to result in lowering the visual acuity should be considered a

disqualification.

h) Squint:-Presence of binocular vision is essential, squint even if the visual acuity is of prescribed standard, should be considered a

disqualification.

i) One eyed person - Presence of binocular vision is essential, one functional eye should be considered a disqualification.

j) There shall be no Nystagmus.

7. Respiratory system: Chest must be well formed Respiratory system should be sound and free from any chronic laryngeal, bronchial

pulmonary disease. Tuberculosis of lungs if not active should not be a disqualification.

a) A full sized postero-anterior chest radiograph (not less than 11 inch. X 14 inch.) enough to include thoracic inlet and both costophrenic

angles obtained by an X-ray machine (analog /digital) of atleast 300 Milli-Ampere strength shall be classified as per ILO international

Classification of Radiographs of Pneumoconiosis by Medical Officer trained in such ILO classification. X-ray shall be classified using

LED view box accommodating at least four chest radiographs of 14 inch. X 17inch size.

b) Lung function tests (spirometry) to record forced vital capacity (FVC) and forced expiratory volume in one second (FEVI) shall be

made. Findings of spirometry shall be within normal limit.

8. Circulatory system: - There should be no evidence of cardiac or vascular disease which may interfere with their efficient employment in a

mine. The Blood pressure shall not be more than 130/80 mm Hg. Detailed cardiovascular assessment of employees should be done. This

should include 12 leads electrocardiogram, echocardiography and complete lipid profile.

9. Locomotor System: The limbs, hands, fingers, feet and toes should be well formed and developed & without any deformity any deformity

and function of all limbs should be within normal limits.

10. There should not be any evidence of disease of abdominal organs which is likely to affect their efficient discharge of duty in a mine.

Ultrasonography (whole abdomen) report shall be normal.

11. In case the candidate has hernia, he may be declared fit after he has been successfully operated for the same.

12. Hydrocele if present should not be large enough to impede the normal activities of the person. If it is large enough he may be declared fit

after being successfully operated.

13. The nervous system should be sound. Persons with history of epilepsy or any other type of organic or historical fits should not be declared

fit for employment in a mine. Detailed neurological examinations including testing of all major superficial and deep reflexes shall be done.

14. Fasting, Post- prandial Blood sugar and Glycoslated Hb level (HbA1c) shall be tested .GlycoslatedHb level (HbA1c) by a medical specialist

as Diabetes Mellitus is known to damage of target organs. GlycoslatedHb level (HbA1c) shall not be more than 6.0. Only such cases of

well controlled Diabetes Mellitus with no associated complications may be considered for appointment.

15. Serum Urea and Creatinine shall be within normal limit.

16. Bilirubin, SGOT and SGPT shall be within normal limit.

17. Routine Stool shall be within normal limit.

18. The medical examination should include examination of urine. Mere presence of albumin and sugar in the urine without any gross organic

disease producing signs and symptoms should not be a disability.

19. There should not be sickle cell disease /trait. Hemoglobin Electrophoresis test shall be done.

Medical Standard of Fitness for Persons Employed (Periodical Medical Examination)

1. The person should be in good mental and bodily health and free from any physical defect likely to interfere with their efficient employment in

a mine.

2. Speech must be without serious impediment.

3. Teeth shall be in good condition and where necessary, the employee shall be provided with dentures, where necessary, for effective mastication

(well filled teeth will be considered as sound). The Gums should be in healthy condition.

4. Locomotor System: The limbs should be well formed and developed, and the function of all the limbs should be within normal limits. Any

deformity should be recorded. There should be no deformity or paralysis which may interfere with their efficient employment in a mine.

5. Skin: - There shall be no evidence of extensive and chronic skin disease or ulceration. In case of infective skin disease, the candidate maybe

declared fit after he has undergoing a treatment. All occupational skin diseases should be noted.

6. Eye :

(a) Vision with or without glass should not be less than the following standard:

i. Better eye 6/9

ii. Worse eye 6/12

(b) There should be no night blindness for persons employed below ground and for persons employed in open cast working in shifts other than in

morning’s shifts.

(c) A person having only one eye which functions normally should not be employed below ground, For employment on surface the vision of such

a person in the other eye should be 6/9with or without glasses.

7. Hearing should be good, any progressive disease affecting hearing/or occupational deafness should be recorded. Audiometric examination shall

be conducted in every case.

8. Respiratory System: Respiratory system should be sound and free from any chronic laryngeal, bronchial pulmonary disease. Tuberculosis of

lungs if not active should not be a disqualification.

a) A full sized postero-anterior chest radiograph (not less than 14 inch. X11 inch.) enough to include thoracic inlet and both costophrenic

angles obtained by an X-ray machine (analog /digital) of at least 300 mA Milli-Ampere strength shall be classified as per ILO international

Classification of Radiographs of Pneumoconiosis by Radiologist / Medical Officer trained in such ILO classification.

b) Lung function tests (spirometry) to record forced vital capacity (FVC) and forced expiratory volume in one second (FEVI) shall be made.

Findings of spirometry shall be within normal limit.

9. Circulatory system – There should be no evidence of any heart or vascular disease which may interfere with their efficient employment in a

mine. Detailed cardiovascular assessment of employees should be done. This should include 12 leads electrocardiogram and complete lipid

profile. The Blood pressure shall not be more than 140/90 mm Hg.

10. There should not be any evidence of disease of abdominal organs which is likely to affect their efficient discharge of duty in a mine.

11. The nervous system should be sound. Persons with history of epilepsy or any other type of organic or historical fits should not be declared fit

detailed neurological examinations including testing of all major superficial and deep reflexes shall be done.

12. Persons exposed to manganese, In addition to the basic neurological examination, special emphasis should be given to behavioral and

neurological disturbances such as speech defect, tremor, impairment of equilibrium, adiadochokinesia and emotional changes.

13. Persons exposed to lead; PME should include delta aminolevulinic acid in urine.

14. Persons engaged in food handling and preparation and handling of stemming material activities should undergo routine sputum for Acid Fast

Bacilli (AFB).

15. Fasting & Post- prandial Blood sugar shall be tested. Diabetes shall be under controlled. Target organ shall not be affected by diabetes.

16. Serum Urea and Creatinine shall be within normal limit.

17. Bilirubin, SGOT and SGPT shall be within normal limit.

18. Routine Stool shall be within normal limit.

19. In case the candidate has hernia he may be declared fit after he has been successfully operated for the same.

20. Hydrocele if present should not be large enough to impede the normal activities off the candidate. In such cases he may be declared fit after

being successfully operated.

The medical examination should include examination of urine and of other system for evidence of disease. Mere presence of albumin and sugar in

the urine without any gross organic disease producing signs and symptoms should not be considered as a disability.