Hong Kong Regulations

FACTORIES AND INDUSTRIAL UNDERTAKINGS REGULATIONS - SCHEDULE 2

1.	Name of industrial undertaking: ...............................................................................
2.	Full name of person employed to work underground: .................................................................................... ....................................................................................
3.	Residential address: ................................................... ....................................................................................
4.	Identity Card No.: ........................................................
5.	Date of birth: ................................................................
6.	Date on which worker first commenced to work underground in the : ...................................................... ....................................................................................	(Full face photograph of worker).
7.	Dates of medical examinations undergone by worker in accordance with regulation 16C(3): (a) ............................................................................ (b) ............................................................................. (c) .............................................................................

Part I. (To be completed in duplicate by the proprietor of the industrial undertaking).
To: ..................................................................................................................... (name of medical practitioner by whom examination is to be carried out)
1.	I, .............................................................................................................................. (full name of proprietor)
	................................................................................................................................. (residential address of proprietor)
	the proprietor of ......................................................................................................... (name of industrial undertaking)
	situated at ................................................................................................................. (address of industrial undertaking)
	request you to examine .............................................................................................. (full name of Employee/proposed Employee*)
	in accordance with regulation 16C(3) of the Factories and Industrial Undertakings Regulations.
2.	This Employee/proposed Employee* is/will be* employed to work underground as a ........... ................................................................................................................................. (specify nature of Employee's/proposed Employee's* occupation) and first commenced/will commence* such work on ................................................... ........................................................ (specify date or proposed date) Date: ....................................... Signature of proprietor: ..............................................................................................

Part II. (To be completed in duplicate by the Employee or proposed Employee).
A	Full Name of Employee/proposed Employee* .......................................................
	Date of Birth .................................................................. Residential Address ..........................................................
B.	History of Past Illnesses. (a) Is there a history of pulmonary tuberculoses? ............... If so give details ........................................................ .................................................................................. .................................................................................. (b) Is there a history of other chronic respiratory disease? ..................................................................................
	................................................................................... ...................................................................................	(Full face photograph of person examined).
	(c) Is there a history of heart disease, diabetes mellitus or any other serious or prolonged disease? ....................................................................................... ....................................................................................................................
C.	Present Complaints (if any). ............................................................................................................................ I declare that to the best of my knowledge the answers given above are accurate. Date: ....................................................... Signature of Employee/proposed Employee*:..........................................................
Part III. (To be completed in duplicate by examining medical practitioner).
A	General Nutrition ................................................................................................. Weight .......................... kg Height .............................. mm Eyes: Visual acuity R. .................... L. ..................... Ears .................................. Cardiovascular System Pulse rate ......................................... B.P. ....................... ............................................................................................................................ ............................................................................................................................ Abdomen ........................................................................................................... Hernias ........................................................................................................ Genito-urinary System ........................................................................................ Urine ..................... Sp.G .................... Alb. ................. Sugar ..................... Skeletal System .................................................................................................. Upper limbs .................................................................................................. Lower limbs ................................................................................................. Nervous System ........................................................................................... .....................................................................................................................
B.	Chest X-ray Examination (date ...........................................) Dr. ..................................................................................................... reports as
	(medical practitioner by whom X-ray examination is made) follows: ............................................................................................................. ............................................................................................................... ...............................................................................................................
C.	I have examined the above named ....................................................................... (full name) in accordance with this report, and consider that he is fit/unfit* to work underground in an industrial undertaking to which Part IIA of the Factories and Industrial Undertakings Regulations applies.
	Date: ........................................................ Signature of Examining Medical Practitioner: ........................................................ Name of Examining Medical Practitioner: ............................................................. (block capitals) Address: ............................................................................................................. ............................................................................................................. Telephone Number: .............................................................................................

(b) * Delete whichever is inapplicable.