FORM-A
(See rule 30)
Certification of Inspection
Inspection Report of the ……………………… Dispensary at ………………………….
by the ………………… for the year ………….. ending …………. 19 .
1. Name of establishment (including factory)/contractor, engaged in the manufacture of beedi, served by dispensary.
2. Number of workers for which it caters.
3. Date and hour of inspection.
4. Date of last inspection.
5. Dispensary buildings-
(a) Condition of dispensary building.
(b) Does the accommodation provided conform to the prescribed standard?
6. Medicines-
(a) Is the supply sufficient and according to the prescribed scale?
(b) Are the poisons labelled and kept separately under lock and key?
7. Surgical instruments and equipment-Are they sufficient and in good order?
8. Staff Acquittance Rolls-Are they in order and up to date?
9. Registers and Returns-Are these properly kept and regularly submitted?
10. Establishment-
(a) Officer-in-charge-
(i) Part-time/Whole-time.
(ii) Name and qualifications.
(b) Designation and pay of staff-
(i) Medical Graduate
(ii) Medical Licentiate.
(iii) Lady Doctor.
(iv) Nurse.
(v ) Compounder.
(vi) Auxiliary Nurse Midwife.
(vii) Male Dresser.
(viii) Female Dresser.
(ix) Sweeper.
(x) Chowkidar.
(xi) Peon.
(c) Attendance Register-Do the staff attends regularly?
11. Annual expenditure on-
(a) Establishment.
(b) Medicines.
12. Out-patients:
(a) Number seen at the time of visit.
(b) Total number of new patients treated in current year up to date.
(c) Total number of old patients treated in current year up to date.
(d) Total treated during the last year,
(e) Do the entries on tickets or patients present tally with the entries on the registers?
(f) Are there any arrangements for treating women apart from men?
13. Are you satisfied with the working of the dispensary? If not, what suggestions can be made for its improvement?
I certify that I have inspected the dispensary noted above and that it conforms/does not conform in the following respects* to the standards laid down in the Beedi Workers Fund Rules, 1978.
Signature of Inspecting Officer
Date......................
Counter-signature of Commissioner
Date........................
*Give details below:
NOTE. -The counter-signature of the Commissioner is not necessary when the Commissioner himself is the Inspecting Authority.
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