OSH Code · Form IX
Form IX — Report of medical examination (in triplicate)
Form IX of the OSH & Working Conditions (Central) Rules 2026, prescribed under Rules 109, 113(1), 119(1), 142.
Rule: Rules 109, 113(1), 119(1), 142 · Signed by: Authorized Certifying Surgeon
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
Part of the Seventh Schedule to the OSH & Working Conditions (Central) Rules 2026. View the official form layout in the gazette, or open the OSH Code forms in MedFactory.
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