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

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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

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