香港附屬法例

工廠及工業經營規例 - SCHEDULE 2

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3. 住址： ............................................................................ .........................................................................................
4. 身分證號碼： .................................................................
5. 出生日期： ....................................................................
6. 工人在上述工業經營中首次開始從事地底工作的日 期：.................................................................................	(工人正面半 身照片)

(a) .....................................................................................
(b) .....................................................................................
(c) .....................................................................................

表格2

[第16C(3)條]

致： ............................................................................................................................

居住於 ........................................................................................................................

為 ...............................................................................................................................

地址為 ........................................................................................................ 的東主，

現請你按照《工廠及工業經營規例》第16C(3)條檢查 .......................................
..................................................................................................................................。
(僱員／準僱員*全名)

....................................................................................................................................

他首次開始從事／將會開始從事*上述工作的日期為 .......................................
.................................................。
(指明日期或建議日期)

日期： ...............................................

東主簽署： .......................................

出生日期 .....................................................................
住址 ............................................................................. ......................................................................................
B. 病歷
(a) 曾否患肺結核？ ....................................................
如曾患此病，請提供細節 ................................... .................................................................................
............................................................................... (b) 曾否患其他慢性呼吸系統病？ .......................... ................................................................................ ...............................................................................	(接受檢查者 正面半身照片)

(c) 曾否患心臟病、糖尿病或其他嚴重或長期疾病？ ............................
......................................................................................................................

C. 目前病患(如有的話)

................................................................................................................................
本人謹此聲明：盡本人所知，上述回答均屬正確無誤。

日期： ..................................................................................................................

僱員／準僱員*簽署： ........................................................................................

A. 一般營養狀況 ..................................................................................................

體重 ...................... 公斤 體高 ................................. 毫米

眼：視力敏銳度 右 ...................... 左 ...................... 耳 ..............................

心血管系統脈搏率 ............................................ 血壓 ...................................
..........................................................................................................................
..........................................................................................................................

腹部 .................................................................................................................

疝 ..............................................................................................................

泌尿生殖系統 .................................................................................................

尿 ................... 比重 .................... 白蛋白 .................... 糖 .....................

骨骼系統 .........................................................................................................

上肢 ..........................................................................................................

下肢 ..........................................................................................................

神經系統 ..................................................................................................
...................................................................................................................

B. 胸部X光檢查(日期 ................................ )
............................................................................................................醫生報告

如下： .........................................................................................................
.......................................................................................................
......................................................................................................

C. 本人已按照本報告檢查上述 ................................................................，
(全名)
並認為他適合／不適合*在《工廠及工業經營規例》第IIA部所適用的工業經營中從事地底工作。

日期： ......................................

進行檢查的醫生簽署： ..........................................................................

進行檢查的醫生姓名： ..........................................................................
(正楷)
地址： ........................................................................................................
........................................................................................................

電話號碼： ..............................................................................................

(b) *刪去不適用者。

表格3

[第16C(4)條]

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本人謹此證明 ............................................................................................ 先生

發出日期： ....................................................................................................... 簽署： ..............................................................................................................
(職業健康科主任醫生)