Format for certificates of fitness for construction workers

Form XI
See rules 223©
Certificate of Medical Examination

1) Certificate Serial No Date:

2) Name
Identification marks if any

3) Father’s Name

4) Sex

5) Residence Son/Daughter of

6) Date of Birth, if available and or age certificate

7) Physical fitness

I hereby certify that I have personally examined ………………………………….(Name)

Son/Daughter/Wife of residing
at who is desirous of
being employed in building and construction work and that his/her age nearly as can be
ascertained from my examination is years and that he/she is fit for
employment in as an adult.

8) Reason for-
a) Refusal of certificate
b) Certificate being revoked

Signature /left hand thumb Signature with seal

Impression of building workers Medical inspector/Doctor

Notes – 1.Exact details of cause of physical disability should be clearly stated.

2. Function/production abilities should also be stated if disability stated

CP 3A (R)/ SHE/ SHR/F-102-05-Rev-01 25-JULY-2018 Page 1 of 2

 Format for certificates of fitness for construction workers

Part – B

Certified that I Dr. -------------------------------- have examined Mr. --------------------------Age ---------On

(date) ---------------------- who has singed below in my presence .General & Physical examination of Mr.
---------------------------------------do not reveal any abnormality. He does not suffer from any acute /
chronic skin disease or any contagious like tetanus, typhoid, cholera or infectious disease. His eye
site is normal with/without glasses. In my opinion, Mr. --------------------------------------------- is physically
and mentally fit for working at heights.

Details of examination are given below:-

Parameters Remarks Parameters Yes No

Height Epilepsy

Chest Frequent headache

Weight Height phobia

Vision Limping gait

Hearing ability Physical deformity

Pulse Flat foot

Blood pressure Mental depression

Respiratory ailments Blood group

Any other information

Signature of Workman Signature & rubber stamp of

Medical Practitioner with Reg No.

CP 3A (R)/ SHE/ SHR/F-102-05-Rev-01 25-JULY-2018 Page 2 of 2