Health Fitness Certificate

for the purpose of permission to work in Confined Space

Name of Person examined:

Date of Birth:

Name and Address of Employer:

I hereby certify that I have examined the abovenamed person on

from the information related to health being declared by the person, my clinical

examination and diagnostic test recorded on medical examination form, I certify that

this worker is for working in confined space.

FIT
NOT FIT

JOY M. ENDAYA,
License No. 268949
MD
Date Attending Physician