Form XXXIII

[See rule 137(2)]

REGISTER OF EMPLOYEES USING

OR HANDLING HAZARDOUS CHEMICALS

The register of Workers engaged in connection with insecticides, chemicals and toxic substances,

and their periodical medical examination for the year......................

Sl. No. Name Father’s/ Husband’s Address Sex Identification Date of Age Designation

Name appointment

PAST HISTORY

Illness Poisoning Allergy Exposure to Pesticides No. of Seasons Years/ Remarks if any

FAMILY HISTORY

Illness Psychological disorders Haemorrhagic disorder

1 2 3

PERSONAL HISTORY

Illness Psychological disorders Haemorrhagic disorder

1 2 3

OBSERVATION

Medicval Pre-employment End of the year Remarks

1. General Examination

a) General body limit

b) Weight and height

c) Blood pressure

d) Respiration

e) Anaemia

f) Diadema

g) Juandice

h) Skin condition

i) Temperature

j) Fatig ability

k) Sweating

l) Sleep

m) Mutation

2. Gastro- Intestinal Nausea

a) vomiting

b) Appetite

c) Taste

d) Pain in abdomen

e) Bowel movement

f) Liver

g) Spleen

3. Cardio-Respiratory

a) Nasal discharge

b) Wheezing

c) Cough

d) Expectoration

e) Tightness of chest

f) Dyspnoea

g) Palpitation

h) Heart

i) Cyanosis

j) Tachycardia

4. Neuro-Muscular

a) Headache

b) Dizziness

c) Irritability

d) Pulse

e) Twitching

f) Tremors

g) Convulsion

h) Paresthesia

i) Hallucination

j) Unconsciousness

k) Deep reflexes

l) Superficial reflexes

m) Coordination

5. Eye

a) Pupil

b) Lachryination

c) Double vision

d) Clumped vision

6. Psychological

a) Temperament

b) Judgment

c) Nervousness

7. Kidney

Kidney condition

8. Investigation

a) Blood Hb%

b) Blood DC

c) Serum

d) Cholinesterase

e) Serum bilirubin

f) Urine routine examination

g) Urine microscopic

h) X-ray of chest

i) Advice given to:

Steps taken by the employer as per the doctor’s advice

1. Doctor

2. Patient

3. Employer