Form V

{See Rule-8 }

HEALTH EXAMINATION

(Except mine employees)

PART –A (Sl.No.1-11):To be filled by the Employee:

1. Name of employee……………………………2.Sex….…..3. Age (withDOB)……..

4. Company………………………………….5.Designation………………5a.UAN: ……

6. In-charge Employer/Executive Contacts………………………………

7. Complete personal/plant Address…………………………………

8. Mobile/Phone…………………………………………

9. Email…………………………………

10. Medical illness (Current) and under treatment & medication, If

any……

11. Nature of Job (furnish more details, if hazardous and work-

relatedviz. Physical, Chemical, Biological, Ergonomic etc). ……………

Date: Signature of Employee

PART-B:

12. Medical Test Carried out & Reports to be Attached as

Annex.Medical Officer’s interpretation/Opinion of the Tests

below(To indicate only if abnormal, referring the attached Test

reports) :

a. Ht.Wt.Chest, Waist Circumference,Body Mass Index:……………………

b. Vision(Ophthalmologist tests):

i. Visual Acuity both Right & left eyes ………………………….

ii. Colour Vision………………………………………………..

c. Blood Pressure………………………………………..

d. Complete Blood Count:………………………………

e. Blood Sugar (Fasting/PPBS/HbAC1)……………….

f. SpO ………………………..

2

g. Blood Urea Nitrogen (BUN)….…………………………..

h. SGOT/SGPT………………………………………………..

i. Lipid profile…………………..

j. ESR………………………………..

k. Thyroid profile………………………………….

l. X-ray Chest etc…………………………………

m. ECG……………

n. Others if any………………………………………….

13. Final Diagnosis/Opinion/Treatment if any, advise by qualified

medical practitioner………….

14. Does the person has seizure (s) related disorders or

difficulties working at Height? If yes,explain the works to be

avoided: Yes/No/ NA (Not applicable)

Date:

Signature of the qualified medical

practitioner

SEAL

NOTE: All the above information is highly confidential between the

Applicant and the Examining Physician. Sharing of the above with

Employer or any other agency/persons is permitted only on obtaining

Consent from the Applicant/Employee.