Form IX — Report of medical examination (in triplicate)

Rule: Rules 109, 113(1), 119(1), 142 · Signed by: Authorized Certifying Surgeon · Under: OSH & Working Conditions (Central) Rules 2026

What the form records

• Certificate No.
• Name of employee (Shri/Smt./Miss)
• Employed as
• Mine
• Employee number
• Employee appears to be (years of age)
• Examined for Initial/Periodical Medical Examination
• (a) Is medically fit for any employment in mines
• (b) Is suffering from
• Medically unfit for any employment in mine
• Medically unfit for any employment below ground
• Medically unfit for any employment or work
• (c) Employee is suffering from
• Should be re-examined within a period of (months)
• Shall appear for re-examination with the result of the test of
• Opinion of the Specialist
• Specialist from
• Employee may be permitted/not permitted to carry on their duties during this period
• Space for affixing Passport Size Photograph of the Candidate
• Place
• Signature & name of the examining authority with date and seal
• Annexure to Certificate No.
• Result of medical examination on
• Identification Mark
• Left thumb impression and Signature of the candidate
• 1. General development (Good/Fair/Poor)
• 2. Height (Cms)
• 3. Weight (kg)
• 4. Eyes: Visual acuity - Distant vision (with or without glasses) - Right eye
• 4. Eyes: Visual acuity - Distant vision (with or without glasses) - Left eye
• Any organic disease of eyes
• Night blindness
• Color blindness (to be tested in IME)
• Squint
• 5. Ears: Hearing - right ear
• 5. Ears: Hearing - Left ear
• Any organic diseases (ears)
• Audiometry - Ear Conduction - Left Ear (Normal/Abnormal)
• Audiometry - Ear Conduction - Right Ear (Normal/Abnormal)
• Audiometry - Bone Conduction - Left Ear (Normal/Abnormal)
• Audiometry - Bone Conduction - Right Ear (Normal/Abnormal)
• 6. Respiratory system: Auscultatory Finding
• Chest measurement after full inspiration (cms)
• Chest measurement after full expiration (cms)
• Spirometry - Forced Vital Capacity (FVC) (Predicted/Performed/% of Predicted)
• Spirometry - Forced Vital Capacity 1 FEV1 (Predicted/Performed/% of Predicted)
• Spirometry - FEV1/FVC (Predicted/Performed/% of Predicted)
• Spirometry - Peak Expiratory Flow (Predicted/Performed/% of Predicted)
• 7. Circulatory system: Blood Pressure
• 7. Circulatory system: Pulse
• Cardiological Assessment - Auscultation - S1
• Cardiological Assessment - Auscultation - S2
• Cardiological Assessment - Auscultation - Additional Sound
• Electrocardiograph (12 leads) findings (Normal/Abnormal)
• Echocardiography finding (to be tested in IME) (Normal/Abnormal)
• 8. Abdomen: Tenderness
• 8. Abdomen: Liver
• 8. Abdomen: Spleen
• 8. Abdomen: Tumour
• Ultrasonography of Whole Abdomen (to be tested in IME)
• 9. Nervous system: History of fits or epilepsy
• 9. Nervous system: Paralysis
• 9. Nervous system: Mental health
• Neurological Assessment - Superficial Reflexes (Normal/Abnormal)
• Neurological Assessment - Deep Reflexes (Normal/Abnormal)
• Neurological Assessment - Peripheral Circulation (Normal/Abnormal)
• Neurological Assessment - Vibrational Syndromes (Normal/Abnormal)
• Manganese exposure - Behavioral Disturbances (Present/Not Present)
• Manganese exposure - Neurological Disturbances - Speech Defect (Present/Not Present)
• Manganese exposure - Neurological Disturbances - Tremor (Present/Not Present)
• Manganese exposure - Neurological Disturbances - Adiadocokinesia (Present/Not Present)
• Manganese exposure - Neurological Disturbances - Emotional Changes (Present/Not Present)
• 10. Locomotory system
• 11. Skin
• 12. Hydrocele
• 13. Hernia
• 14. Teeth
• 15. Speech
• 16. Pathological Investigations - Blood-Tc, Dc, Hb, ESR, Platelets (WNL/Abnormal)
• 16. Blood Sugar - Fasting & PP (WNL/Abnormal)
• 16. HbA1c (to be tested in IME and for diabetic person during PME) (WNL/Abnormal)
• 16. Lipid profile (WNL/Abnormal)
• 16. Blood Urea, Creatinine (WNL/Abnormal)
• 16. Urine (Reaction, Albumin, Sugar) (WNL/Abnormal)
• 16. Stool Routine (WNL/Abnormal)
• 16. Sputum test for AFB (For Food handling employee)
• 16. Hemoglobin Electrophoresis for sickle cell disease/trait (to be tested in IME) (WNL/Abnormal)
• 16. Bilirubin (WNL/Abnormal)
• 16. SGOT (WNL/Abnormal)
• 16. SGPT (WNL/Abnormal)
• 16. Delta aminolevulinic acid in urine (for person exposed to Lead) (WNL/Abnormal)
• 17. Skiagram of chest - ILO Classification - Profusion of Pneumoconiotic opacities (Present/Absent)
• 17. Skiagram of chest - ILO Classification - Grades
• 17. Skiagram of chest - ILO Classification - Types
• 18. Any other abnormality
• 19. Any other test considered necessary by the examining authority
• 20. Any opinion of specialist considered necessary
• Place
• Signature & name of the examining authority with date and seal

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

MedFactory — Occupational Health Centre software for Indian factories