【法规名称】
【法规编号】 81847 什么是编号？
【正 文】
第7页 CAP 59A FACTORIES AND INDUSTRIAL UNDERTAKINGS REGULATIONS
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[接上页] Date of birth: ................................................................ 6. Date on which worker first commenced to work underground in the : ...................................................... .................................................................................... (Full face photograph of worker). 7. Dates of medical examinations undergone by worker in accordance with regulation 16C(3): (a) ............................................................................ (b) ............................................................................. (c) ............................................................................. ___________ FORM 2 [regulation 16C(3)] FACTORIES AND INDUSTRIAL UNDERTAKINGS REGULATIONS MEDICAL EXAMINATION REPORT Part I. (To be completed in duplicate by the proprietor of the industrial undertaking). To: ..................................................................................................................... (name of medical practitioner by whom examination is to be carried out) 1. I, .............................................................................................................................. (full name of proprietor) ................................................................................................................................. (residential address of proprietor) the proprietor of ......................................................................................................... (name of industrial undertaking) situated at ................................................................................................................. (address of industrial undertaking) request you to examine .............................................................................................. (full name of Employee/proposed Employee*) in accordance with regulation 16C(3) of the Factories and Industrial Undertakings Regulations. 2. This Employee/proposed Employee* is/will be* employed to work underground as a ........... ................................................................................................................................. (specify nature of Employee's/proposed Employee's* occupation)and first commenced/will commence* such work on ................................................... ........................................................ (specify date or proposed date) Date: ....................................... Signature of proprietor: .............................................................................................. Part II. (To be completed in duplicate by the Employee or proposed Employee). A Full Name of Employee/proposed Employee* ....................................................... Date of Birth .................................................................. Residential Address .......................................................... B. History of Past Illnesses. (a) Is there a history of pulmonary tuberculoses? ............... If so give details ........................................................ .................................................................................. ..................................................................................(b) Is there a history of other chronic respiratory disease? .................................................................................. ................................................................................... ................................................................................... (Full face photograph of person examined). (c) Is there a history of heart disease, diabetes mellitus or any other serious or prolonged disease? ....................................................................................... .................................................................................................................... C. Present Complaints (if any). ............................................................................................................................ I declare that to the best of my knowledge the answers given above are accurate. Date: ....................................................... Signature of Employee/proposed Employee*:.......................................................... Part III. (To be completed in duplicate by examining medical practitioner). A General Nutrition ................................................................................................. Weight .......................... kg Height .............................. mm Eyes: Visual acuity R. .................... L. ..................... Ears .................................. Cardiovascular System Pulse rate ......................................... B.P. ....................... ............................................................................................................................ |
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