Rule Form VIII Form VIII
- Chapter
- Annexures · Forms and Appendices
- Text as on
- As notified 08 May 2026
FORM-VIII photo (See rule 5(2)) HEALTH EXAMINATION (Except mine employees)
PART --A (Sl.No.1-11) : To be filled by the Employee:
1. Name of employee......................................................2. Gender.... ..... 3. Age (with DOB)........
4. Company........................................ 5.Designation.....................................5(a). UAN:............... 5(b) Aadhaar Number (after obtaining consent)
6. In-charge Employer / Executive Contacts.......................................
7. Complete personal /plant Address .......................................
8. Mobile /Phone ...................................................... 9.Email.......................................
10. Medical illness (Current) and under treatment & medication, If any....................................
11. Nature of Job (furnish more details, if hazardous and work-related viz. Physical, Chemical, Biological, Ergonomic etc)
.............................................
Date: Signature of Employee
PART-B: 12.Medical Test Carried out & Reports to be Attached as AnnexureDefined in rule 2(d): Annexure means list annexed to these rules; (2) The words and expressions used in these rules and are not defined therein, but are defined in the Code, shall have meanings respectively assigned to them in the Code. . Medical Officer's interpretation/ Opinion of the Tests below (To be indicated only if abnormal , with reference to the attached Test reports) :
a. Ht. (in cm) b. Wt. (in Kg) c. Chest measurement:
(i) On inspiration ............cm Yes/No/ NA
(ii) On expiration ............ cm
(d) Waist Circumference
(e) Body Mass Index: ........................
(f) Vision (Ophthalmologist tests):
i. Visual Acuity both Right & left eyes ............................... ii. Colour Vision........................................................
(g) Blood Pressure (mm Hg)...............................................
(h) Complete Blood Count: (Hb, TLC, DLC, Platelets).........................
(i) Fasting Blood Sugar
(j) Post Prandial Blood Sugar...................
(k) SpO2.............................
(l) Blood Urea ....................................
(m) S. Creatinine ................................
(n) S. Bilirubin (Total + direct)
(o) SGOT
(p) SGPT........................................................
(q) Lipid profile (S. Cholesterol / Triglyceride / S.HDL) ........
(r) S. TSH ......................................
(s) X-ray Chest (PA view) .......................................
(t) ECG...............
(u) Others if any................................................. 13.Final Diagnosis/ Opinion / Treatment if any, advise by qualified medical practitioner .....................
14. Does the person have seizure (s) related disorders or difficulty in working at height ? If yes, specify the works to be avoided: (Not applicable)
Date: Signature of the qualified medical practitioner SEAL
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