(In respect of persons employed in Building and other construction work involving hazardous process

Name of the Construction Medical Officer/Medical Inspector-

(a) Mr. ……………………………………...…….. From. ………………………..
(b) Mr. ……………………………………...…….. From. ………………………..
(c) Mr. ……………………………………...…….. From. ………………………..

Name of building
Sl. No. Works No. Sex Age (last birthday)
worker

1 2 3 4 5

Notes:
(i) Column (8): Detailed summary or reason for transfer or discharge should be stated.
(ii) Column (12) should be expressed as fit/unfit/suspended.
 FORM XXXIII
[See clause (g) of rule 242 ]
RECORD OF MEDICAL EXAMAINATION/HEALTH RE

work involving hazardous processes)

to. …………………………
to. …………………………
to. …………………………

Date of
Date of leaving or Reason for leaving, Nature of job or
employment of
transfer to Other work transfer or discharge occupation
present work

6 7 8 9

e should be stated.
 FORM XXXIII
See clause (g) of rule 242 ]
ICAL EXAMAINATION/HEALTH REGISTER

Date of Medical examination

Raw material or by Result of medical
by certifying Surgeon Medical
product handled examination
Inspector/CMO

10 11 12
 If suspended from work, Certified fit to resume duty
If certificate of unfitness or
state period of suspension on with signature of Medical
suspension issued to worker
with detailed reasons Inspector/CMO

13 14 15

Signature with date of Medical Inspector/CMO