Age Verification & Fitness Certificate of garments | Garments-Info

  Age & Physical fitness verification Form

 Identification:

1.      (Name)                              :.....................................................

2.      (Father's/Husband's Name) :.....................................................

3.      (Mother’s Name)                :.....................................................

4.      (Permanent Address)  :.....................................................

         (Village):......................................................  (P.O):.....................................................

         (U.P./P/S/):........................................  (Dist):......................................................

5.      (Date of Birth - Examiner's opinion)  :.....................................................

6.    (Examiner's Consent) :

       (I am giving permission consciously to examine me with a view to determine my age) 

      (Signature/Thumbing) (Date)

7.    (Physical Examination):

         a) Height:................. b) Weight:.................. c) Blood pressure:................. 

           d) Eruption of Teeth-8/7 in 19 years and above,                    7/7 & 7/7 in 14          to 18 years

         e) Growth of mustache and beard- in case of male only

☐ Complete:                           ☐ Incomplete:

         f) Menstruation -in case of female, on set of menstruation.................................................

         g) Drug Screening : Drug Addiction : □(Yes) □ (No)

         h) Other:

8.  (Determination of Eye):

a) Visual Acquity                     □ 6/6 □6/9 □6/12 □6/24

(By Sneller's Chart)                                        

b) Color Vision)                     □ Normal □ Abnormal

(By Sneller's Chart)

c) Squint eyed?                         □ Yes □ No

d) Diplopia?                             □ Yes □ No

e) Nystagmus?                         □ Yes □ No

f) Ptosis?                                 □ Yes □ No

9.  (Doctor's Opinion):

(Based on above examination and observation, examiner's approximate age is .................. years and he/she is physically fit/unfit for working in garment factory.)

........................

(Signature & Seal of Doctor)                                 (Signature of worker)                     

(Date):......./......../20.......                                        (Date):......./......../20......            Thumb