FORM NO.

20
(Prescribe under Rule 15)
Health Register
(In respect of persons employed in occupations declared to be dangerous
operations under section 87).
Name of Certifying urgeon. (a) !r. ""..
#rom ""..$o"".
(b) !r. ""..
#rom ""..$o"".
(c) !r. ."".
#rom ""..$o"".
%erial
No.
&or's
No.
Name of
(or'ers
e) *ge(last
birt+ day)
,ate of
employment
of present
(or'
,ate of
lea-ing or
transfer to
ot+er (or'
1 . / 0 5 1 7
Reason for lea-ing2
transfer or
disc+arges
Nature of 3ob or
occupation
Ra( material or
4y5product +andled
,ate of medical
e)amination by
Certifying urgeon
Result of !edical
6)amination
8 7 18 11
Note 9
(i) Column 8.5,etailed summary of reason for transfer or
disc+arge s+ould be stated.
(ii) Column 11.5+ould be e)pressed as fit:until:suspended.
If suspended from
(or'2 state period of
suspension (it+
detailed reason
Certified fit to
resume duty on (it+
signature of
Certifying urgeon
If certificate of
unfitness or
suspension order
issued to (or'er
ignature (it+ date
of Certifying
urgeon
1. 1/ 10 15