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Format No. 1-2019-PSS-01 Rev.1

The document appears to be a medical certificate for contract employees working at heights or in confined spaces at the BPCL Kochi Refinery. It collects information on the employee's medical history, physical examination results, vision tests, and pulmonary function tests. The examining medical officer then provides their recommendation on whether the employee is fit for working at heights or in confined spaces.

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nithin
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472 views1 page

Format No. 1-2019-PSS-01 Rev.1

The document appears to be a medical certificate for contract employees working at heights or in confined spaces at the BPCL Kochi Refinery. It collects information on the employee's medical history, physical examination results, vision tests, and pulmonary function tests. The examining medical officer then provides their recommendation on whether the employee is fit for working at heights or in confined spaces.

Uploaded by

nithin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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BPCL KOCHI REFINERY, AMBALAMUGAL

CONTRACT EMPLOYEE – WORKING AT HEIGHT / CONFINED SPACE


CERTIFICATE OF MEDICAL EXAMINATION
Certificate serial no.
NAME: AGE: years DATE :

FATHER’S NAME: BPCL PASS NO/AADHAR NO:

SEX: Male / Female CONTRACTOR NAME: PETROFAC SUB CONTRACTOR NAME: NEO STRUCTO
OCCUPATION : RCM / LSO/ SITE ENGINEER/ SUPERVISOR/ SAFETY OFFICER/ QAQC/ OFFICE STAFF/ DRIVER/ WELDER/HELPER/KHALASI/
ELECTRICIAN /OTHERS

HISTORY
Hypertension yes/no

Diabetes Mellitus yes/no

Seiztires yes/no

BronchialAsthma yes/no

Fainting spells yes/no

Medicallons

Habits: Alcohol: Smoking: pan chewing:

PHYSICAL EXAMINATION

General condition : Normal/obese

Pulse: ________________ b/min Ht. _________ cms

BP : ________________ mm/Hg Wt. _________ kgs

INVESTIGATIONS

Eye Vision :

For Working at Height

Titmus Vision Testing

Romberg’s Test

Straight Line Walking Test

Tandem Walking Test

For Working In Confined Space

Pulmonary Function Test

RECOMMENDATION FOR PHYSICAL FITNESS

I hereby certify that I have personally examined (name)………………………………………………………………….son/daughter/wife of


…………………………………………..residing at ………………………………………………….who is desirous of being employed in building and construction work
and that his/her age as nearly as can be ascertained from my examination is …………..years and that he/she is fit for employment in
…………………………………………..as an adult

Fitness for height work: YES/NO Fitness for confined space: YES/NO

Reason for Refusal of certificate:

Recommendation if any for further investigation:

Left thumb impression/sign of employee signature of medical officer with seal

Format No. 1-2019-PSS-01 Rev.1 Perfect Safety Solutions

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