Form VI

[See rule 6]

Certificate of fitness for employment in hazardous process and Operations

(To be issued by Factory Medical Officer)

1. Serial No. register of adult workers :

2. Name of the person examined :

3. Father’s Name :

4. Sex :

5. Residence :

6. Date of birth, If available :

7. Name and address of the factory :

8. The workers is employed or proposed to be employed:

a) Hazardous:

b) Dangerous operation:

Certify that I have personally examined the above named person whose identification marks are

………………………… And who is desirous of being employed in above mentioned process/operation

and that his/her age, as nearly as can be as certained from my examination is .............................. Years.

In my opinion he/she is fit for the said manufacturing process/operation.

In my opinion he/she is fit for employed in the manufacturing process/operation for the reasons

………………………………

He/she is referred for further examination to the Medical Officer. The serial number of the

previous certificate is ………………………

Signature or left thumb impression of Signature of the Factory Medical Officer

the person examined.

Stamp of factory medical officer with name of the factory

I certify that I examined the person mentioned above on (date of examination I extent this

certificate will (if certificate is not extended, the period for which the workers is considered is unfit for work

to be mentioned Signs and symptoms observed during examination Signature of the factory medical officer

with date

Notes: 1. If declared unfit, reference should be made immediately to the Medical Officer.

2. Medical Officer should communicate his finding to the occupier within 30 days of receipt

of this reference.