Return to index New query |
Department of Industrial Relations Division of Occupational Safety and Health MEDICAL EXAMINATION FOR HOISTING ENGINEERS (To be sent to the project manager) Name of Applicant______________________________________ Address_______________________ Employer______________________________________________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 Back to Tunnel Safety Orders, Article 24 Table of Contents