Rule Form X Form X
- Chapter
- Annexures · Forms and Appendices
- Text as on
- As notified 08 May 2026
FORM- X [See rule 119 (2)]
Certificate medical re-examination by Appellate Medical Board
(To be issued in triplicate)
We do hereby certify that we have examined Shri/ Smt. /Miss............ employed as .......... in ........., Employee number......... ., who was declared medically unfit for.
1. any employment in mine.
2. any employment belowground.
3. any employment in work..........
(Specify in details)
After re-examination, we consider that --
1. Employee is medically fit for any employment in mine.
2. Employee is suffering from........... and is medically unfit for
(a) any employment in mine.
(b) any employment belowground.
(c) any employment in work..........
(Specify in details)
3. Employee is suffering from...........and should get this disability/cured/controlled and be re-examined within a period of .........months. Employee shall appear for re-examination within a period of............months. Employee shall appear for re-examination with the result of the test
of ......... and opinion of the ......... specialist from.......... . Employee may be permitted/may not be permitted to carry on their duties during this period.
Paste colour passport size photograph Signature & Name of members of Appellate Medical Board with date Attested by manager/agent/owner 1.....................(Convenor) 2.............. 3...............
Report of the Appellate Medical Board
AnnexureDefined in rule 2(d): Annexure means list annexed to these rules; (2) The words and expressions used in these rules and are not defined therein, but are defined in the Code, shall have meanings respectively assigned to them in the Code. to certificate No.............as result of Medical examination on................
Identification mark :
Left thumb impression & Signature of the candidate
1. General development- Good/Fair/Poor
2. Height............Cms.
3. Weight............kg.
4. Eyes :
(i) Visual acuity-Distant vision (with or without glasses): Right eye........ Left eye..............
(ii) any organic disease of eyes
(iii) night blindness
(iv) Colour blindness
(v) Squint
5. Ears :
(i) Hearing : right ear.............Left ear .................
(ii) Any organic diseases.
Audiometry Findings if required :
Conduction Type Left Ear Right Ear Ear Conduction Normal/Abnormal Normal/Abnormal Bone Conduction Normal/Abnormal Normal/Abnormal Enclosed Audiometry Report.
6. Respiratory system. Auscultatory Finding: Chest measurement :
(i)after full inspiration ............cms.
(ii)After full expiration..............cms.
Result of Lung Function Test ( Spirometry) if required
Parameters Predicted Value Performed Value % of Predicted
Forced Vital Capacity (FVC)
Forced Vital Capacity 1 FEV1
FEV1/FVC
Peak Expiratory Flow
Spirometry Report enclosed
7. Circulatory system:
Blood Pressure :-
Pulse :-
Cardiological Assessment
Auscultation S1
S2
Additional Sound
Electrocardiograph (12 leads) findings : Normal/Abnormal Normal/Abnormal Echocardiography finding if required
Enclosed ECG
Enclosed Echocardiography report
8. Abdomen : Normal/Abnormal Tenderness. Liver. Spleen. Tumour.
9. Nervous system: History of fits or epilepsy Paralysis. Mental health.
Neurological Assessment Findings Superficial Reflexes Deep Reflexes Peripheral Circulation Vibrational Syndromes
10. Locomotory system
11. Skin.
12. Hydrocele.
13. Hernia.
14. Any other abnormality
15. Urine :
Reaction: Albumin: Sugar:
16. Pathological Investigations:
S.No. Tests Findings WNL/Abnormal 1 Blood-Tc,Dc,Hb,ESR, Platelets WNL/Abnormal WNL/Abnormal 2 Blood Sugar- Fasting & PP WNL/Abnormal WNL/Abnormal 3 HbA1c if required WNL/Abnormal WNL/Abnormal 4 Lipid profile
5 Blood Urea, Creatinine
6 Urine Routine
7. Hemoglobin Electrophoresis (if required)
Enclosed all Investigation Reports.
17. Skiagram of chest. Types
18. ILO Classification of Chest Radiograph :
Profusion of Pneumoconiotic Grades opacities Present/Absent Enclosed Chest Radiograph
19. Any other test considered necessary by the examining authority.
20. Any opinion of specialist considered necessary.
Signature & Name of members of Appellate Medical Board with date 1.....................(Convenor) 2.............. 3...............