TAMILNADU ELECTRICITY BOARD
(CERTIFICATE OF PHYSICAL FITNESS (FOR CLASS III / IV SERVICE)
(This form is to be used by every candidate who is required by the Tamilnadu Electricity Board to produce the certificate of physical fitness. It must be signed by a Medical Officer of rank not lower than that of an Asst.Surgeon, employed under the Government of Tamilnadu or by an Honorary Asst.Surgeon and Physician appointed by the Government of Tamilnadu to a Government Medical Institution).
NOTE: A candidates who resides outside Tamilnadu and who is unable to produce the medical certificate from a medical officer employed in Tamilnadu may produce it from a medical officer of corresponding rank out side Tamilnadu. Such certificate should contain the following particulars.
1. The state under which the medical officer is employed and the name of the institution in which he is employed and his rank.
2. Register number of the certifying medical officer in the register in which his name has been registered.
3. The official stamp seal of the institution in which the certifying medic al officer is employed. The certificates so produced will be subject to acceptance after scrutiny by the Director of Medical service, Tamilnadu.
NAME AND RANK OF OFFICER GRANTING THE CERTIFICATE;
I do hereby certify that I have examined (FULL NAME) ………………………………………………………………………… a candidate for employment under the Tamilnadu Electricity Board in the ………………………………………………………………………………
……………………………………………………………………… Service as ……………………………………………………. and cannot discover that he has any disease communicable or otherwise, constitutional affection or bodily in firmity except that his weight is (in excess of/below) …………………………… that standard prescribed or except ………………………………………. I do / do not consider this a disqualification for the employment he seeks.
...2...
/2/
I do further certify that in my opinion his general physical condition is such as to enable him to perform efficiently the active duties of executive services.
His age is according his own statement ……………… years and by appearance about ……………………… years.
I also certify that he has marks of smallpox/vaccination.
Chest measurement in cms. (On full inspiration)
(On full expiration)
(Difference expansion)
Height in cms…………… Blood Pressure:
Weight in Kgs…………… Systolic: Diastolic:
HIS VISION IS NORMAL;
Hypermetropic (……………………………………………………………………………
Here enter the degree of defect and strength ofcorrection glasses)
Myopic (……………………………………………………………………………
Here enter the degree of defect and strength
of correction glasses)
Astigmatic (Simple or mixed) (……………………………………………………………………………
Here enter the degree of defect and strength
ofcorrection glasses)
Hearing is normal/defective (much or slight)
Urine –does chemical examination so (1) Albumin. (2) Sugar
State specific gravity:
PERSONAL MARKS (at least two should be mentioned):
1)
2)
Station: ……………………………………………………
Date: ……………………………………………………
/3/
CANDITATE’S STATEMENT AND DECLARATION
The candidate must make the statement required below prior to his Medical Examination and must sign the declaration appended therein. His attention is specifically directed to the warning contained in the note below:-
1) State your name in full (in block letters):
2) State your age and place of birth :
3) A) Have you ever had small pox,
Intermittent or any other fever.
Enlargement or suppuration of
Glands. Spitting of blood, asthma,
Heart disease, lung diseases,
Fainting attacks, rheumatism,
Appendicitis?
(or)
b) Any other disease or accident
Requiring confinement to bed and
Medical or surgical treatment? :
c) Suffered from any illness, wound
or Injuries sustained while on
active Service during the war
of 1939-1946? :
4) When were you last vaccinated? :
5) Have you or any of your near
relations been affected with
consumption, scrofula, gout, :
Asthma, fits, epilepsy or insanity?
6) Have you suffered from any form of?
Nervousness due to over work or any
Other causes? :
7) Have you been examined and
declared unfit for Government :
Service by a Medical Officer/
Medical Board, within the
last three years?
8) Furnish the following particulars
Concerning your Family
Father’s age if living and state of health
|
Father’s age a death and cause of death
|
No. of brothers living their ages and state of helth
|
No. of brothers dead, their ages, at and cause of death
|
Mother’s age if living and state of health
|
Mother’s age a death and cause of death
|
No. of sisters living their ages and state of helth
|
No. of sisters dead, their ages, at and cause of death
|
1. I declare all the above answers to b, to the best of my belief, true and correct.
2. I also solemnly affirm that I have not received a disability certificate /Pension on account of my disease or other condition.
Signed in my presence.
Signature of Medical Officer Candidate’s Signature.
Note; The candidate will be held responsible for the accuracy of the above statement. By willfully suppressing any information, he will incur the risk losing the appointment and, if appointed, of forfeiting all claims to superannuation allowance or Gratuity.
No comments:
Post a Comment