Department of Labour and Employment FORM -26 Certificate of fitness for dangerous operations (See schedule VI, XI and XVII to rule 105) 1. Serial No. Serial No. 2. Name of person examined I certify that I have personally examined son of __________________ residing at _____________Who is desirous of being employed as ____________________ in ascertained from my examination, is fit / unfit for employment at the above noted factory. 2. He is fit to be employed and may be employed on some other non hazardous operation such as 3. Father's Name 3. He may be produced for further examination after a period a 4. Sex 4. He is advised following further examination: 5. Address 5. He is advised following treatment: 6. Name of the factory in which 6. The serial number of the previous certificate employed in which and L.T.I. of person examined. wished to be employed. 7. Process of department in which employed / wishes to be employed. 8. Whether certificate granted 9. Whether declared unfit and certificate refused. 10. Reference number of previous certificate granted or refused Signature of Certifying Surgeon * L.T.I of person examined Note: 1. The counterfoil should be retained by the certifying surgeon and maintained in a bound book or in a file. The para which does not apply may be cancelled. Signature of Certifying Surgeon
