Form X

[See rule 119 (2)]

Certificate medical re-examination by Appellate Medical Board

(To be issued in triplicate)

We do hereby certify that we have examined Shri/ Smt. /Miss………… employed as ………. in ………, Employee number……… ., who

was declared medically unfit for.

1. any employment in mine.

2. any employment belowground.

3. any employment in work……….

(Specify in details)

After re-examination, we consider that –

1. Employee is medically fit for any employment in mine.

2. Employee is suffering from……….. and is medically unfit for

(a) any employment in mine.

(b) any employment belowground.

(c) any employment in work……….

(Specify in details)

3. Employee is suffering from………..and should get this disability/cured/controlled and be re-examined within a period of ………months.

Employee shall appear for re-examination within a period of…………months. Employee shall appear for re-examination with the result of the test

of ……… and opinion of the ……… specialist from………. . Employee may be permitted/may not be permitted to carry on their duties during

this period.

Signature & Name of members of Appellate Medical Board with date

Paste colour passport size photograph

Attested by manager/agent/owner 1…………………(Convenor)

2…………..

3……………

Report of the Appellate Medical Board

Annexure to certificate No………….as result of Medical examination on…………….

Identification mark :

Left thumb impression & 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) Colour blindness

(v) Squint

5. Ears :

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

(ii) Any organic diseases.

Audiometry Findings if required :

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) if required

Parameters Predicted Value Performed Value % of Predicted

Forced Vital Capacity (FVC)

Forced Vital Capacity 1 FEV1

FEV1/FVC

Peak Expiratory Flow

Spirometry Report enclosed

7. Circulatory system:

Blood Pressure :-

Pulse :-

Cardiological Assessment

Auscultation S1

S2

Additional Sound

Electrocardiograph (12 leads) findings : Normal/Abnormal

Echocardiography finding if required Normal/Abnormal

Enclosed ECG

Enclosed Echocardiography report

8. Abdomen :

Tenderness.

Liver.

Spleen.

Tumour.

9. Nervous system:

History of fits or epilepsy

Paralysis.

Mental health.

Neurological Assessment

Findings Normal/Abnormal

Superficial Reflexes

Deep Reflexes

Peripheral Circulation

Vibrational Syndromes

10. Locomotory system

11. Skin.

12. Hydrocele.

13. Hernia.

14. Any other abnormality

15. Urine :

Reaction:

Albumin:

Sugar:

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 if required WNL/Abnormal

4 Lipid profile WNL/Abnormal

5 Blood Urea, Creatinine WNL/Abnormal

6 Urine Routine WNL/Abnormal

7. Hemoglobin Electrophoresis (if required) WNL/Abnormal

Enclosed all Investigation Reports.

17. Skiagram of chest.

18. ILO Classification of Chest Radiograph :

Profusion of Pneumoconiotic Grades Types

opacities

Present/Absent

Enclosed Chest Radiograph

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

20. Any opinion of specialist considered necessary.

Signature & Name of members of Appellate Medical Board with date

1…………………(Convenor)

2…………..

3……………