OSH Code · Form X (Form 10)
Form X — Certificate of medical re-examination by Appellate Medical Board
Form X of the OSH & Working Conditions (Central) Rules 2026, prescribed under Rule 119(2).
Rule: Rule 119(2) · Signed by: Authorized Certifying Surgeon
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
OSH Code Form X is the 10th form of the Seventh Schedule, so it is also written OSH Code Form 10. Both refer to this same form: Certificate of medical re-examination by Appellate Medical Board.
Part of the Seventh Schedule to the OSH & Working Conditions (Central) Rules 2026. View the official form layout in the gazette, or open Form X in MedFactory.
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