FORM O
See rules 29F (2), and 29L

Report of medical examination under rule 29B
(Issued in triplicate)**
Certificate No.
Certified that Shri/Shrimati* employed as ........................ in ........................ mine, Form B No. has been examined for an initial/periodical* medical examination. He/she* appears to be ............................. years of age. The findings of the examining authority are given in the attached sheet. It is considered that Shri/Shrimati*...........................................
(a) * Is medically fit for any employment in mines.
(b) * Is suffering from ............................. and is medically unfit for
(i) Any employment in mine; or
(ii) Any employment below ground; or
(iii) Any employment or work ........................................
(c) * is suffering from ..................................., should get this disability* cured/controlled and should be again examined within a period of ................. months. *He/she will appear for re-examination with the result of test of ............... *and the opinion of ................... Specialist from ......................... He/She* may be permitted/not* permitted to carry on his duties during this period.
 Signature of the examining authority
.......................................
Name and designation in block letters.
Place :
Date :
Report of the examining authority
(To be filled in for every medical examination whether initial or periodical or re-examination or after cure / control of disability).
Annexure to Certificate No. ...................... as a result of medical examination on .................................. Identification Mark………………………..
Left thumb impression of the candidate.
1. General development. Good/Fair/Poor
2. Height ..................................Cms.
3. Weight .................................Kg.
4. Eyes:
(i) Visual acuity—Distant vision (with or without glasses).
Right eye ................... Left eye....................
(ii) Any organic disease of eyes
*(iii) Night blindness.
*(iv) Colour blindness.
*(v) Squint.
(*To be tested in special cases)
5. Ears:
(i) Hearing Right ear .............. Left ear ...............
(ii) Any organic disease.
6. Respiratory system.
Chest measurement:
(i) After full inspiration ............. cms.
(ii) After full expiration ............. cms.
7. Circulatory system:
Blood pressure.
Pulse.
8. Abdomen:
Tenderness.
Liver.
Spleen.
Tumour.
9. Nervous system:
History of fits or epilepsy.
Paralysis.
Mental health.
10. Locomotor system
11. Skin.
12. Hernia.
13. Hydrocele.
14. Any other abnormality.
15. Urine:
Reaction
Albumin.
Sugar.
16. Skiagram of chest.
17. Any other test considered necessary by the examining authority.
18. Any opinion of specialist considered necessary.
Signature of the examining authority
Place :