Serial No. | Work No. | Name of Worker | Sex | Age (last birthday) | Date of employment on present work | Date of leaving or transfer to other work | Reason for leaving transfer or discharge | Nature of Job or occupation | Raw material or By product handled | Dates of medical Examination by Certifying Surgeon | If suspended from work, state period of suspension with detailed reasons. | Recertified fit to resume duty on (with signature of Certifying Surgeon) | If certifying of unfitness or suspension issued t o worker | Signature with date of Certifying Surgeon |
