FORM 28 (prescribed under various schedules to Rule 160) CERTIFICATE OF FITNESS Serial No........ I certify that I have personally examined (name) _________________________________________ ___________________________________ son of _____________________________________________ residing at _____________________________________________________________________________ who is desirous of being employed as (designation) ____________________________________________ in (process, department and factory) ________________________________________________________ ______________________________________________________________________________________ and that his age, as nearly as can be ascertained from my examination, is _______________ years, and that he is, in my opinion, fit / unfit for employment in the above mentioned factory as mentioned above. 2. He may be produced for further examination after a period of _________________________. 3. The serial number of the previous certificate is ________________________________. Signature or left hand thumb impression of person examined Signature of Certifying Surgeon Date I certify that I examined the person mentioned above on I extend this certificate until (if certificate is not extended, the period for which the worker is considered unfit for work is to be mentioned) Signs and symptoms observed during examination Signature of the certifying surgeon 1 2 3 4
