The Occupational Safety, Health and Working Conditions (Andhra Pradesh) Rules, 2026
Form : XXVI
Official text
Open in the official PDF (pp. 486–488)
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(see rule 120, Schedule-II)
CERTIFICATE OF FITNESS
photo
1. Name & Address of the Factory
2. Serial No.
3. Name
4. Father's Name
5. Sex
6. Residence
7. Date of Birth / or certified age
8. Physical Fitness
9. Descriptive marks
10. If already employed, Nature of
work
11. Raw materials or by products
handled
12. Date of employment on present
work
13. Result of last Medical
Examination, if any:
14. Result of present Medical
Examination/
Symptoms and signs observed.
15. If suspended from work, state
period of
suspension with detailed reasons
16. If recertified, fit to resume duty
on
17. If Certificate of unfitness or
suspension issued to worker
18. Date of leaving or transfer with
reasons for discharge or transfer
19. Certificate extended upto
20. He is advised following further
examination/treatment
21. I hereby certify that I have personally examined .......... S/D/W of
.................... residing at .................... who is desirous of being
employed in a factory and that his/her age as nearly as can be
ascertained from my examination, is ................ years and he/she is fit
for employment in factory as an adult/child in Mfg. /handling process viz
................................
His/her descriptive marks ...........................
Signature of
Health Surveillance Officer / Medical Officer
Signature/Thumb Impression of
worker...................................................................
22. Reasons for
1. Refusal of certificate
2. Certificate being revoked
Signature of Health Surveillance
Place:
Officer / Medical Officer
Date: