INTERGRATED CRYOGENIC ENGINE STAGE & TEST FACILITY9ISRO 2)IPRC MEHENDRAGIRY

Screening of Worker
Worker ID No Date.
Photo
Name of the contractor / Sub –Contractor:.

Full Name of the workmen:.

Father / Husband’s Name:.

Permanent Address: .

Date of Birth Sex Age Years

Marital Status: Married / Single / Widow / Widower Number of Children .

Mother Tongue Other Languages Known .

In case of emergency person to be contacted .

(with address and Telephone Number if any)

Any other identification mark:

Vision Normal If not Normal; specify the problem

Health Normal
Weight KG Height Cms Blood group

Education details
Examination Passed Year School / Board

Please obtain photocopy of birth certificate issued by school or Gram Panchayat as required under Workmen’s
Compensation Act,1923
Previous work experience
SI.No. Organization Name Project Site Category Period Salary / Wage

Declaration by the Subcontractor / Contractor

We declare that this employee will be working for us in this side He / She shall follow the entire site safety
requirement We take responsibility for his/her safety in the site
Signature of the Contractor
Screened by me Certificates / Details verified / not verified

Suitable for employment as

Site in charge /Site Engineer

TRAIL REPORT: -Seen and briefed the EHS rules of the site

Safety Officer