DGMS Form J To U
DGMS Form J To U
DGMS Form J To U
[FORM – J]
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[See Rule 76 (1)
Introduction :
Col (5) : Specify as indicated in Annexure – 1 Col (6): Specify as indicated in Annexure – II, Col. (7) :
Give brief description of the circumstances attending the accident.
Col. (11) : Specify whether simple wound laceration abrasion of fracture (only toes, fingers and thumb etc)
Col. (14) : mention the days intervening the days of occurrence and day of rejoining and not including
either the date of occurrence or rejoining.
Col. (16) : In case if an injury proves “Serious” or “Fatal” or when injured person proceeds on leave or
leaves his employment. Particulars should be entered in this column.
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[Note : Copies of entries person injured in preceding quarter(s) and who continued to absent in the quarter
should also be submitted separately]
Classification of Accident
By place of work (Column – 5)
1. Below ground :
2. Opencast Workings :
ANNEXURE – II
1.Ground movements :
4.1 Drills
4.2 Coal cutting Machinery
4.3 Coal Loading Machinery
4.4 Haulage Engine
4.5 Winding Engine
4.6Shovels, Draglines, Excavators etc.
4.7 Ore handling Plants (including crushing and screening plants)
4.8 Pumps
4.9 Other (specify)
5. Explosive
6. Electricity
7. Dust Gas and other combustible material :
9. Other Cause :
Name of Mine……………..
State………….District…………
Owner……………………….
Mineral worked…………(Quarter ending on…)
Sl. No. from Nature of Nature Parts of body Date of return of Initial of attending Remarks
Register in employment of injury injured injured person to medical practitioner
Form B work
9 10 11 12 13 14 15
1.
2.
3.
4.
5.
Introduction :
Col (5) : Specify as indicated in Annexure – 1 to Form J. Col (6): Specify as indicated in Annexure – II
to From J. Col. (7) : Give brief description of the circumstances attending the accident.
Col. (11) : Specify whether simple wound laceration abrasion of fracture
Col. (15) : In case if an injury proves “reportable” “Serious” or “Fatal” or when injured person proceeds on
leave or leaves his employment. Particulars should be entered in this column.
1. Substituted by GSR 316 dated 26.4.1986
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[FORM – L
Signature
Designation: Owner/agent/manager
Mine :
Owner :
Dated ………………………….
No………….. Date………………….
Shri/Shrimati*…………. May note that if he/she* fails, without reasonable cause, to submit
himself/herself* for the medical examination aforesaid he/she shall not be eligible for
appointment/continuance in employment to the mine from………………
Shri/Shrimati*……………. May further note that he/she* should bring with him/her* three unattested
photographs of himself/herself* and the previous medical certificates in Form O, if any, issued to
him/her* under rule 29 F.
Signature of manager
…………………mine
*Delete whatever is not applicable
** Necessary only in case of a person already employed in the mine.
*** In respect of the initial medical examination of a person already employed in a mine and in respect
of every periodical medical examination atleast twenty days prior notice is to be given. In respect of
the initial medical examination of a person seeking employed at a mine the period of notice may be
shorter.
Note – A copy of the notice shall be sent to the examining authority concerned. In the case of
periodical medical examination, the copy of medical certificate in Form O shall also be sent.
1. Inserted by GSR 1786 dated 17.10.1970
2. Inserted by GSR 557(E) dated 16.11.1978
1{FORM – N}
No……… Date………….
He/She* is hereby again notified that he/she* should present himself/herself* for an
initial/periodical* medical examination, under rule 29B of the Mines Rules, 1955, before……….(give
name of the examining authority) at ……(give date)** ……..at……….(give time)
Shri/Shrimati*…………, may note that if he/she* fails to submit himself/herself* for the medical
examination aforesaid, he/she* shall not be employed/retained in employment in the mine from………
Shri/Shrimati*………….., may further note that he/she* should bring with him/her* three
unmounted photographs of himself/herself* and he previous medical certificate in Form O, if any,
issued to him/her* under rule 29F.
Signature of Manager
Certified that Shri/Shrimati* employed as ………. In ………mine, Form B No. has been
examined for an initial/periodical medical examination. He/she* appears to be………… years of age. The
findings of the examining authority are given in the attached sheet. It is considered that
Shri/Shrimati*…………..
©* is suffering from………… is should get this disability* cured/controlled and should be again examined
within a period of ………..months. He/She will appear for re -examination with the result of test
of………… and the opinion of …………Specialist from………… He/She may be permitted/not*
permitted to carry on his duties during this period.
6.Respiratory system.
Chest measurement :
7. Circulatory system:
Blood Pressure
Pulse
8. Abdomen :
Tenderness.
Liver.
Spleen.
Tumour.
9. Nervous system:
History of fits or epilepsy
Paralysis.
Mental health.
10.Locomotory system
11. Skin.
12. Hydrocele.
13. Hernia.
14. Any other abnormality
15. Urine :
Reaction.
Albumin.
Sugar.
16. Skiagram of chest.
17. Any other test considered necessary by the examining authority.
18. Any opinion of specialist considered necessary.
Place:
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(FORM – P)
1. The pers on should be in good mental and bodily health and free from any physical defect likely to
interfere with his efficient employment in a mine.
2. Skeletal nervous system : The limbs should be well formed and developed, and the function of all the
limbs should be within normal limits. Any deformity should be recorded. There should be no
deformity or paralysis which may interfere with his efficient employment in a mine.
3. Skin :- There should be no evidence of extensive and chronic skin disease or ulceration. In case of
infective type of skin disease, the candidate could be made fit after he has undergone a treatment. All
occupational skin diseases should be noted.
4. (a) Eye vision should be not less than the following standard:
6. Speech must be without serious impediment. Unless this is also accompanied by generalised partial
paralysis this should not be a reason for declaring unfit.
7. (a) Respiratory system should be sound and free from any chronic bronchial or laryngeal disease.
This however alone should not be reason to make unfit.
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(b) [A full sized pestero-anterior chest radiograph (large) enough to include thoratic inlet and
both costophrenic angles obtained by an X-ray machine of atleast 300 mA Milli-Ampere)
strength shall be evaluated in the manner specified by the Chief Inspector and Lung function
tests (spirometry) to record forced vital capacity (FVC) and forced expiratory volume in one
second (FEVI) shall be made. There should not be any evidence of active pulmonary disease
if] there are evidences of active pulmonary tuberculosis, he may be permitted to work if his
sputum is negative on repeated examination and on production of a certificate that he is taking
treatment from a qualified medical practioner/hospital
8. Circulatory system – There should be no evidence of any heart or vascular disease which may interfere
with his efficient employment in a mine.
9. In case the candidate has hernia he may be declared fit after he has been successfully operated for the
same.
10. Hydrocele if present should not be large enough to impede the normal activities off the candidate. In
such cases he may be declared fit after being successfully operated.
11. The medical examination should include examination of urine and of other system for evidence of
disease. Mere presence of albumen and sugar in the urine without any gross organic disease producing
signs and symptoms should not be considered as a disability.
1. The person should be in good mental and bodily health and free from any physical defect likely to
interfere with his efficient employment in a mine. Due allowance in the standard should be made for the
age of a candidate.
2. Locomotor system – The limbs should be well formed and developed and the function of all the limbs
should be within normal limits. Any deformity should be recorded. There should be no deformity or
paralysis which may interfere with his efficient employment in a mine. Any deformity noted should be
recorded.
3. Skin – There should be no evidence of extensive and chronic skin disease or ulceration.
4. (a) Distant vision eye with or without glasses should be not less than the following standard.
For workers employed on For workers employed
Surface and in opencast below ground
Workings
1. Better eye 6/12 6/6
2. Worse eye 6/18 6/9
(b) Night blindness should be tested in special cases only in underground workers where the examining
authority considers it necessary.
(c) A person having only one eye which functions normally should not be employed belowground. For
employment on surface the vision of such a person in the other eye should be 6/12 with or without glasses.
A person will be considered uni-ocular when there is physical loss of one eye or when there in functional
loss of vision of one eye.
(d) Colour blindness will be tested only in special cases where the job requires good colour dis crimination.
Only low grade colour perceptions will be tested with Edridge Green’s lantern.
(f) There should not be any organic disease of the eye which is likely to affect the distant vision within a
period of five years.
5. Hearing should be good. Any progressive disease effecting hearing should be recorded. The candidate
should be able to hear conversational voice from a distance of 3 metres.
7. (a) Respiratory system should be sound and free from any chronic laryngeal bronchial pulmonary
disease. Tuberculosis of lungs if not active should not be a disqualification.
(b) 2 [A full sized pestero-anterior chest radiograph (large) enough to include thoratic inlet and both
costophrenic angles obtained by an X-ray machine of atleast 300 mA Milli-Ampere) strength shall be
evaluated in the manner specified by the Chief Inspector and Lung function tests (spirometry) to record
forced vital capacity (FVC) and forced expiratory volume in one second (FEVI) shall be made. There
should not be any evidence of active pulmonary disease if] there are evidences of active pulmonary
tuberculosis, he may be permitted to work if his sputum is negative on repeated examination and on
production of a certificate that he is taking treatment from a qualified medical practioner/hospital
1. Substituted by GSR 707(E) dated 21.7.1989
2. Substituted, ibid
8.Circulatory system :- There should be no evidence of cardiac or vascular disease which may interfere
with his efficient employment in a mine.
9. There should not be any evidence of disease of abdominal organs which is likely to affect his efficient
discharge of duty in a mine.
10. In case the candidate has hernia, he may be declared fit after he has been successfully operated for the
same.
11. Hydrocele if present should not be large enough to impede the normal activities of the person. If it is
large enough he may be declared fit after being successfully operated.
12. The nervous system should be sound. Persons with history of epilepsy or any other type of organic or
historical fits should not be declared fit for employment in a mine.
13. The medical examination should include examination of urine. Mere presence of albumen and sugar in
the urine without any gross organic disease producing signs and symptoms should not be a disability.
14. Skiagram of the chest should also he obtained. If it is necessary the medical officer may direct the
candidate to obtain the result of special tests or/and the opinion of a specialist from recognised
institution/hospital.
(FORM – Q)
No……….. Date………………..
MEMORANDUM
Signature of manager
……………………mine.
Medical Board
No………….. Date……………19
MEMORANDUM
He/She* is hereby again notified that he/she* should present himself/herself* for a medical re -examination
by the Appellate Medical Board at ……..(give exact description of place) on**……….(give date) at
…………(give time).
Shri/Shrimati*…..may note that if he/she* fails to submit himself/herself* for the medical re -examination
aforesaid, he/she* shall not be retained in employment in the mine.
Signature of Manager
……………….. mine.
(FORM – S)
(Specify in details)
as a result of a medical examination under rule 29B. Our Report is given overleaf.
We consider that –
3. He/She is suffering from…..and should get this disability/cured/controlled* and should be again
examined within a period of ……………months. He will appear for re -examination within a period
of…………months. He will appear for re-examination with the result of test of………* and opinion of
………specialist from…………He may be permitted/not permitted* to carry on his duties during this
period.
Signature of members of
Appellate Medical Board
1…………………(Convenor)
2………….. 3……………
* Delete whichever is not applicable
**One copy of the certificate shall be handed over to the person concerned and another copy shall be sent to the manager of the mine
concerned by registered post, and the third copy shall be retained by the Convener of the Appellate Medical Board.
5. Ears :
6. Respiratory system :
Chest measurement
8. after full inspiration …….cms (ii) after full expiration……
7. Circulatory system :
Blood pressure…………. Pulse…………..
8. Abdomen :
Tenderness……..Liver……..Spleen…………Tumour………..
9. Nervous system :
History of fits or epilepsy…..Paralysis……..Mental health………
10. Locomotion system :
11. Skin :
12. Hernia :
13.Hydrocele :
14.Any other abnormality :
Urine: Reaction…….. Albumin……… Sugar………..
15.Skiagram of chest :
16.Any other test considered necessary by the examining authority.
17.Any opinion of specialist considered necessary.
(FORM – T)
1. Name of mines………………
2. Postal address of Mines……………
3. Date of opening ………………..
4. Date of closing (if closed)………….
5. Situation of Mine (District/State)…………..
6. Name of Owner………..Postal address of owner…………
7. Number of persons required to be medically examined……….
9. Number of persons medically examined……………
10. Number of persons declared medically unfit…………
11. Categorisation of the persons declared unfit………….
Certified that the information given above is correct to the best of my knowledge.
Date……………… Signature……………..
(No. S. 650/2/1/72-M.L.)
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(FORM – U)
Date……..Designation
1. Inserted by GSR 316 dated 26.4.1986