Form X — Certificate of medical re-examination by Appellate Medical Board

Rule: Rule 119(2) · Signed by: Authorized Certifying Surgeon · Under: OSH & Working Conditions (Central) Rules 2026

What the form records

• Name of employee (Shri/Smt./Miss)
• Employed as
• In (mine)
• Employee number
• Declared medically unfit for any employment in mine
• Declared medically unfit for any employment belowground
• Declared medically unfit for any employment in work (Specify in details)
• After re-examination - Employee is medically fit for any employment in mine
• Employee is suffering from
• Medically unfit for any employment in mine
• Medically unfit for any employment belowground
• Medically unfit for any employment in work (Specify in details)
• Employee is suffering from (and should get this disability cured/controlled)
• Be re-examined within a period of (months)
• Employee shall appear for re-examination within a period of (months)
• Re-examination with the result of the test of
• Opinion of the specialist
• Specialist from
• Employee may be permitted/may not be permitted to carry on their duties during this period
• Paste colour passport size photograph (Attested by manager/agent/owner)
• Signature & Name of member of Appellate Medical Board with date - 1 (Convenor)
• Signature & Name of member of Appellate Medical Board with date - 2
• Signature & Name of member of Appellate Medical Board with date - 3
• Annexure to certificate No.
• Result of Medical examination on
• Identification mark
• Left thumb impression & 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
• Colour blindness
• Squint
• 5. Ears: Hearing - right ear
• 5. Ears: Hearing - Left ear
• Any organic diseases (ears)
• Audiometry Findings if required

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

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