Cal. Code Regs. Tit. 8, div. 1, ch. 4, subch. 20, app C
Department of Industrial Relations Division of Occupational Safety and Health
MEDICAL EXAMINATION FOR HOISTING ENGINEERS
(To be sent to the project manager)
Name of Applicant _____________________Address _________________________
Employer _______________________ Address ___________________________
Record of Past Employment
Employer _______________________Address ___________________________
Absence from work during past 6 months and reasons ___________________________
Total years' experience as hoisting engineer ______________________________ Licensed ______________________________ Where ___________________________
Date of last medical exaimination, if any ___________________________
Place of birth ________________________Date ___________________________
Marital Status ___________________________
Are you in good health? ___________________________
Have you had problems with:
Vision? ____________________ Fainting spells? ____________________ Dizzy Spells? ____________________ Heart trouble? ____________________ Epileptic Seizers? ___________________________
Alcohol/drugs? ______________________________ Have you a first-aid certificate? ______________________________
Year issued? _______________________________
By whom __________________________________________________ I certify that all my answers to the above are correct and true and that I have also read the "Orders for Hoist Engineers" in the Mine Safety Orders.
| Date ___________________________ | ___________________________ | |
| Signature of Applicant |
Physician's Report
1. Age ____________________ Weight ______________________________ Height ______________________________
Temperature _________________________ Blood pressure ___________________________
2. Vision: Right eye ______________________________ Left eye __________________________________________________ Color Perception __________________________
3. Hearing: Right ear ____________________________________________________________ Left ear ___________________________
4. Nose and throat: Normal _______________________________________________________ Abnormal ___________________________
5. Chest: Expiration ___________________________________________________________ Inspiration ___________________________
6. Heart: Rhythm ______________________________ Size ______________________________ Ausculation ______________________________ Pulse ___________________________
7. Abdomen: Scars or hernia ___________________________
8. Spine ________________________________________ Deformities __________________________________________________ Rigidity ___________________________
9. Genito-urinary system ___________________________
10. Urinalysis ___________________________
11. Hemorrhoids ______________________________ Varicose veins ___________________________
12. Defects of joints, bones or muscles ___________________________
13. Does applicant appear to be addicted to stimulants or narcotics? ___________________________
14. Posture: Excellent ________________________________________ Good ________________________________________ Fair ________________________________________ Bad ___________________________
15. Reflexes: Patella ________________________________________ Rhomberg ______________________________ Rabinski ______________________________ Coordination ___________________________
16. Nervous or composed ____________________________________________________________ Tremors ___________________________
17. Mental Agitation? ___________________________ Medical Reasons for rejection, if any ___________________________ Date __________________________________________________ Physician's Name __________________________________________________ M.D. ___________________________
Address_________________________
..........................
Detach and post in the hoist house
Hoist Engineer's Medical Examination
The medical examination of Mr. __________________________________________________ leads me to believe he is physically able to assume the duties of a hoisting engineer as of this date.
| ___________________________ | ___________________________ | ___________________________ |
| City | Date | Physician's Signature |
Cal. Code Regs. Tit. 8, div. 1, ch. 4, subch. 20, app C
2. Editorial correction establishing separateHISTORIES for appendix (Register 2003, No. 28).
Note: Authority cited: Sections 142.3 and 7997, Labor Code. Reference: Sections 142.3 and 7997, Labor Code.