Name of Employee                                                                                

ID Number                                                                                              

Co. Number                                                                                            

*Possible Exposures

e.g. noise, heat, fall risk, confined space etc.

*Job Specific Requirements

e.g. Operating Mobile Crane, Digging

Trenches, Erecting Formwork and Supportwork

etc.

*Protective

Equipment

e.g. Dust Respirator

(Light Duty), Welding

Gloves etc.

*Occupation

e.g. General Worker, Welder, Bricklayer, Steel fixer, Mobile Crane Operator, etc

*The Employer to complete the information in the spaces marked with an * before sending the Employee for a medical examination

Declaration by the Medical Examiner:

I certify that I have, by examination and testing, using the above criteria specified by the employer, satisfied myself that the abovementioned employee is fit to perform the duties as described by the employer in the matrix above.

Occupational Medicine Practitioner/Occupational Health Nursing Practitioner: (Please Print Name:)                                                                        

Signature:                                                                              Practice Number:                                                          Date:                                                                

Address: