Department of Labour and Employment FORM - 16 A (Prescribed under rule 16) Health Register SI No Dept / Works Name of the Worker Age at last Birth day Date of employm ent in present work Date of leaving or Transfer (with reasons for discharge or transfer) Nature of Job on occupation Raw materials / by products handled Date of weekly exams with results (fit / unfit) Nature of Symptoms Signature of a Reg. medical Practitioner (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)
