This information is provided free of charge by the Department of Industrial Relations from its web site at These regulations are for the convenience of the user and no representation or warranty is made that the information is current or accurate. See full disclaimer at

Subchapter 20. Tunnel Safety Orders
Article 24. Licensing of Blasters

Return to index
New query

Appendix C

Department of Industrial Relations
Division of Occupational Safety and Health

(To be sent to the project manager)

Name of Applicant______________________________________ Address_______________________

Record of Past Employment

Employer__________________________________________ Address_____________________________
Absence from work during past 6 months and reasons_____________________________________
Total years' experience as hoisting engineer__________ Licensed____________ Where______
Date of last medical examination, if any_______________________________________________
Place of birth________________________________________________________ Date____________
Martial Status_________________________________________________________________________
Are you in good health?________________________________________________________________
Have you had problems with:
Vision? __ Fainting spells?__ Dizzy Spells? ___  Heart Trouble? ___ Epileptic Seizers? __
Alcohol/drugs?____________ Have you a first-aid certificate?________ Year issued?_______
By whom_________________________  I certify that all my answers to the above are correct
and true and that I have also read the "Orders for Hoist Engineers" in the Mine Safety Orders.

____________________________	__________________________________________________
Date                                 Signature of Applicant

Physician's Report

1. Age__________ Weight________ Height _______ Temperature ______ Blood pressure_______
2. Vision: Right eye _________________ Left eye_______________ Color Perception________
3. Hearing: Right ear_______________________________ Left ear__________________________
4. Nose and throat: Normal __________________________ Abnormal ________________________
5. Chest: Expiration ________________________________ Inspiration______________________
6. Heart: Rhythm ___________________ Size ___________ Ausculation_________ Pulse ______
7. Abdomen: Scars or hemia ____________________________________________________________
8. Spine ___________________________ Deformities_________________ Rigidity ____________
9. Genito-urinary system ______________________________________________________________
10. Urinalysis_________________________________________________________________________
11. Hemorrhoids__________________________________ Varicose veins ______________________
12. Defects of joints, bones or muscles _______________________________________________
13. Does applicant appear to be addicted to stimulants or narcotics? __________________
14. Posture: Excellent ________________ Good ______________  Fair _____________ Bad____
15. Reflexes: Patella __________ Rhomberg ___________ Rabinski ______ Coordination_____
16. Nervous or composed ___________________________________________ Tremors ___________
17. Mental Agitation? _________________________________________________________________
Medical Reasons for rejection, if any _________________________________________________
Date _______________________________ Physician's Name __________________ M.D.__________
Address _______________________________________________________________________________

Hoist Engineer's Medical Examination

The medical examination of Mr. ____________________ leads me to believe he is physically
able to assume the duties of a hoisting engineer as of this date.
_______________________________	________________	____________________________
    City                           Date                  Physician's Signature

Go BackGo Back to Tunnel Safety Orders, Article 24 Table of Contents