[Prescribed under Schedule XXI to Rule 95]

Health Register

Serial Number Department/Works Name of worker Sex Age last birthday} Date of employment on present work Date of leaving or transfer to other work with reasons of discharge or transfer Nature of job / occupation Raw material, bi-products likely to be exposed to   Date of medical examination and results thereof   Signs and symptoms observed during examination Nature of tests and results thereof If declared unfit for work, state period of suspension with reason in detail Whether certificate of unfitness issued to the workers Re-certified to resume duty on Signature of the certifying surgeon with date
                  Date   Result Fit or unfit