(CONFIDENTIAL)

EOL/HSF/OHC/R/038

Medical Examination For Agency Staff (OSBL)

Name Agency Name:-
Card No Department:-
Date of
Area of work:-
Examination
Date of Birth Age in years:-
Mark of
Allergic to:-
identification
H/o any
Date of Joining:-
Accident/Injury
Past History Diabetes/Hypertension/Heart Diseases/Cancer/Asthma/TB/Convulsion
Personal history Smoking/alcohol/tobacco

Measurements:
Chest Weight Expiration
Height (cm)
Inspiration (cm) (Kg) (cm)

Vital signs:-
Pulse /min R. R. /min
B. P. mm Hg Temp

Eyes:
Squint: - Nystagmus:-
Far Vision Near Vision
Right Left Right Left
Without Glass
With Glass
Power of
glasses
Colour Vision
Remarks:

Ear:
Whispered Voice @ 2 feet
distance
Tympanic Membrane (R) (L)
Any Disease

Nose & Throat:

Teeth Gums
Tongue Oral cavity
Tonsils Remarks:

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Occupational Health and Medical Services, Essar Oil Limited, Vadinar
 (CONFIDENTIAL)
EOL/HSF/OHC/R/038

Medical Examination For Agency Staff (OSBL)

Cardio Vascular System:

Respiratory system:
Gastro-Intestinal System:
Central Nervous System
Skeletal System
Skin and Genitals

Investigations:
ECG RBS :
Total WBC count : RBC : Platelet :
Differential Count N: L: E: M: B:
Hb % : Blood Group :

Urine Examination:
Colour : Microscopy:
Reaction : Pus cells :
Sugar : RBCs :
Albumin : Cast / Crystals

Observations FIT / UNFIT / TEMP. UNFIT

Signature with seal of examining Doctor and Date

Registration number:

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Occupational Health and Medical Services, Essar Oil Limited, Vadinar
 (CONFIDENTIAL)
EOL/HSF/OHC/R/038

Medical Examination For Agency Staff (OSBL)

Certificate of Fitness of Employment in Hazardous Process and Operation

Form No.33
(Prescribed under Rule 68-T and 102)

1. Serial Number in the register :

2. Name of the person examined :
3. Father’s Name :
4. Sex :
5. Residence :
6. Date of birth, if available :
7. Name & address of the factory :EOL VADINAR
8. The worker is employed / proposed :
(a) Hazardous process :
(b) Dangerous operation :

I 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 ascertained from my
examination, is ______________ years.

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

In my opinion, he / she is unfit for employment in the said manufacturing process / operation for
the reason _____________________. He/She is referred for further examination to the
certifying surgeon.
The serial number of previous certificate is OHC/___________/AGENCY/ /

Signature or Left hand thumb Signature of Factory Medical Officer

impression of the person examined Stamp of factory
Medical officer with
Name of the Factory:
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Occupational Health and Medical Services, Essar Oil Limited, Vadinar
 (CONFIDENTIAL)
EOL/HSF/OHC/R/038

Medical Examination For Agency Staff (OSBL)

Date:-

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Occupational Health and Medical Services, Essar Oil Limited, Vadinar