MEDICAL FITNESS CERTIFICATE FOR EMPLOYEES

Part – A

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 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

Any other information

Signature of Workman Signature & rubber stamp of Medical Practitioner with Reg No.

Part – BSafety Section

The applicant has appeared the following practical test conducted by Safety Dept (Strike off whichever not applicable) a) Walking freely over horizontal bar at 1 ft : Pass / Failb) Wearing a safety belt and trying the rope knot : Pass / Failc) Walking over a horizontal structure at 1.8 mtr. Height wearing a belt : Pass / Fail d) General physique (OK/ Not OK) : Pass / Fail

The above applicant’s performance in the above tests has been satisfactory / unsatisfactory .So; I satisfied issue of this height pass to Shri ----------------------------------

with Registration No ----------------------------------- in the height pass register. This is valid for one year from the date of issue.

Date: Seal with Signature Safety Manager/ Engineer

To, The Medical OfficerDate:

APPLICATION FOR HEIGHT PASS(To be filled by the individuals of company employees, sub contractor/PRW/Agency)

Part—A

1. Applicant Name : --------------------------------------------2. Occupation/designation : --------------------------------------------3. Residential Address : --------------------------------------------4. Age : --------------------------------------------5. Sex : --------------------------------------------6. Height : --------------------------------------------7. Gate pass No. : --------------------------------------------8. Name of the contractor / Agency With whom engaged at present : --------------------------------------------9. Description of present job : --------------------------------------------10. Previous experience of working at height: -----------------------------------

SL. No. Name of Employer Duration of Employment Total Work Experience

1.2.

11. Is the applicant suffering from any of the following aliment (If yes detail to be given)a) Blood Pressure -----------------b) Epilepsy ----------------c) Flat Foot --------------------d) Frequent head ace or reeling sensation-------------------------------e) Mental depression -----------f) Limping gait ------------- h) Height Phobia----------------Part BDECLARATION: I hereby declare that the above information furnished by me is true and correct. I shall always wear the safety belt and tie the lifeline whenever working at unguarded heights of 2 meter and above. I shall not misuse the height pass issued to me or transfer it to other person. I shall never come to duty or work at height / depth under the influence of alcohol / drugs.Date: Name: Sign: (Applicant Name & Signature or L.T.I. (Left Thumb Impression) In the case, he can not sign. Note: In case the applicant is illiterate, an authorized person shall explain each point / item to the individual. I certify that I am satisfied with the above certification of the individual of the application of height pass and request for issue of height pass to him.Name:Sign & Date:(Required only in case of Sub contractor/PRW/other Agency Employees )