Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee

Sheet Number

Form No. 21
(Prescribed Under Rule 19)

HEALTH REGISTER

In respect to persons employed in occupations declared to be dangerous operations under section 87

Name of Certifying Surgeon :

(1)	Serial No. :
(2)	Deptt & Code No. :		[]
(3)	Name of Employee :
(4)	Sex :
(5)	Date of Birth :
(6)	Age	No DOB Found
(7)	Aadhar No. :
(8)	Mobile No. :
(9)	Date of employment on Present work :
(10)	Date of leaving transfer to Other work :
(11)	Reason of leaving transfer or Discharge :
(12)	Name of job or occupation :
(13)	Raw material or by product handled :
(14)	FORM O :
(15)	Incharge :
(16)	Bloodgroup :

URINE:R-M-

Investigations :

Date:23/01/2026

Signature of Employee