Form 12

(see rule 28)

Health Check-up for employee

PART–A

(Sl. No. 1-11) : To be filled by the Employee:................. Date.....................

Note.— Exact details of cause of physical disability should be clearly stated.

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

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………………………………

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11. Nature of Job (furnish more details, if hazardous and work-related viz. Physical, Chemical, Biological,

Ergonomic etc)

………………………………………

Date: Signature of Employee

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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 ………………………..

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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………………………………………….

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

14. Does the person have 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.

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