Form 5 — Certificate of Fitness

Rule: Rule 19(2) · Signed by: Authorized Certifying Surgeon · Under: Factories Act 1948 / Model Factories Rules 2020

General fitness certificate issued by Certifying Surgeon — for young persons (Sec 69) and women/adolescents in restricted processes.

What the form records

• Serial Number + Date
• Name of person examined
• Father's name
• Sex
• Residence
• Date of birth / certified age
• Physical fitness (fit as adult / child)
• Descriptive marks
• Reason for refusal (if any)
• Signature/thumb of examined person
• Signature of Certifying Surgeon

This page opens the blank statutory form in MedFactory, ready to fill, save and print. See the Form 5 reference page for the rule and signatory detail.

MedFactory — Occupational Health Centre software for Indian factories