FORM No.

39
[See sub-rule (4) of Rule 65-B]

Record of eye examination

SI. Department/ Name Sex Age (on Occupation Examination of eye Signature of Remarks
No. Works of last sight Ophthalmologist
Worker birthday) Nature Date Result

1 2 3 4 5 6 8 9 10 11

Signature of the Manager

(Name in Block letters).