JSW Steel works

Salem Works
High Risk Job Medical Fitness - Requisition Form
Contractors Name: Date:

Work order no:

To
The Factory Medical Officer,
M/S JSW Steel Ltd,
Salem.

Subject: Requisition for examining the fitness for our employees - Reg.

Respected Sir,

The listed workgroup has undergone specialised training on the below mentioned
job. We request you to kindly examine them and issue their fitness as per the test report.

Working at Height: Confined Space Entry: Gas Line Work:

Authorization:
Approval 1.User Dept. 2.Training Dept. 3. Safety Dept.
Name
Signature

Yours Sincerely,

Supervisor Name

Supervisor Signature

Doc No: SHE/FR/19 Rev No:00 Date: 22-06-2019