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Vertigo or Height Fobia Test

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Keerthi Raaj
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337 views2 pages

Vertigo or Height Fobia Test

Uploaded by

Keerthi Raaj
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
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FORM-XXXIL As per BOCW act 1996 [See clause (0 of rule 242] CERTIFICATE OF M EDICAL EXAMI TION 1. Certificate No: 2. Date: Project Name & Location: Name of employee: QUAD... MOREA... SMA. 4 $8. Date of Birth: ...RINAMIAA Goer Age aay 6. 808! Dn can: Wentification marks: 1. ECB. 26 RG. AE MOEIIER scereorve 8. Father's Name: .. HA D@}0Y.... JIM 9. Residence Address: Cont EBB OBS as 10. Phy: ical Fitness: C- bs micalay. Urey enify thane psonally examined nae ASvinn.. Kame... Son/ Daughter / Wife of ey 4 Residing at.....lo3..Z2 who is desirous of being caployed int in budding/and construction work and that his/her age as nearly as can be ascertained from my examination is ..Z>.... years and that he / she / is fit for employment ne ALE 1G: in IE oso ‘as an adult / adolescent. Is there any COVID-19 symptoms identified: Yes /Nh— Ares ec II. Certificate being revoked 2 Dr. BAD oy Pa phase +fon hand thumb Ae Impression of building worker Medical Inspector Note: I. Exact details of eause of physical disability should be clearly stated 2. Funetional / productive abilities should also be stated if disability is stated Blood Group: ~——RI, Type: ya Height : J¢,° ems Chest SF FD ems Weight: toy kes Visual Acuity: Ro fy fl, Loy BP mm of Ha, Color Blindness + PYygy "etre Pulse: per min RAS; mgt Temp. : & cr Spo2: Pe Working At Height Certification (Height Phobia). Dat Name of employee T2109 kumoe Gre Age: 2ey Gender: Meertnr Name of the company/contract; § (Q-LY 1G History of previous medical /surgical illness:— 100 - If any concerns: ters Examination Details Shorey General Examination Normal On Height Blood Pressure sige |'3e Jae Pulse Rate/min So &Y soon ae Mh Respiratory Rate War Wat Facial xpression Greovel Cree! Height Phobia ~An- |= No- Any other significant (Nystagmus/vertigo etc.) ~ NO- vO" 1D an Rfarorearnen tiles. Zax nite careful examination ofthe case certify that this employee is medically Fit/Unfit to work at height of .. OW. mit/felrwith necessary safety precautions & safety equipment's. Dr. BANUs Reg ‘Oth Dostor se31& signat ‘Tata Communications - General -

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