The Mizoram Occupational Safety, Health and Working Conditions Rules, 2026
Form XXI
Official text
Open in the official PDF (pp. 225–226)
Tables and forms lose their layout when extracted; the PDF is the authoritative version.
{See rule 42 (3)(b) & 43}
Certificate of fitness for Adolescent
Space for passport size
Photograph of the young
Person examined.
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. Referred by :
a Name and address of the factory :
b Name of Manager :
c. Manufacturing process in which young :
Person is proposed to be employed
I certify that I have personally examined the named person whose identification marks
are and who is desirous of being employed in the above mentioned manufacturing process,
and that his/her age, as nearly as can be ascertained from my examination is ------------------------
years, and that he/ she is * fit/unfit for employment in the said manufacturing process an *adult/
child.
Physical disability, if any………………
Reasons for refusal/revocation of certificate:
Signature or left hand thumb impression
of the person examined
Signature of Certifying Surgeon Name
(in block letters)
Date:
Notes:-
a) To be issued by the Medical Officer and a copy to be retained for 2 years.
b) As per the proviso to sub-section (2) of Section 69, the Medical Officer issuing this certificate
should have personal knowledge of the place where the young person proposes to work and of
the manufacturing process in which he will be employed.
c) As per Section 69 (3) of the Act this certificate is valid for one year from the date of issue.
d) In case of physical disability the exact details should be clearly stated.
e) Please delete what is not applicable.
f) Young person mean a child (who has completed 14 years and not completed 15 years) or and
adolescent (who has completed 15 years and not completed 18 years of age).
Information to be furnished by Occupier of Hazardous process Industry to the
Chief Inspector-cum-Facilitator
1. Name of Factory ……………………………
2. Address ……………………………
3. No of workers ……………………………
4. No of workers in hazardous process ……………………………
5. Product ……………………………
6. Manufacturing process ……………………………
7. Hazardous processes involved ……………………………
8. Details of Chemicals involved …………………………
Name of Chemical Maximum Storage Capacity
1 Raw Materials
A
B
C
Etc
2 Intermediate Products
A
B
C
Etc
3 Finished Product
A
B
C
Etc.
9 Hazards associated with the Factory …………………………… …
10 Fire & Explosion risk …………………………… …
11 Safety Measures …………………………… …
12 Details of hazardous waste generation & disposal …………………………… …
Signature of Occupier