OSHWC Form IX: mine medical-examination report

Mine-specific initial/periodical/re-examination certificate, clinical report and prescribed fitness standards, issued by the examining authority.

See rule 109, rule 113(1) , rule 119(1) and rule 142 · Central Rules 2026 · appropriate-government scope

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Fictional completed mine medical-examination report; the selected facts and alternative branches are stated explicitly. It is not a genuine submission or official output.

Fictional, unsigned completed illustration. It demonstrates this form’s fields; it is not a filed return, medical opinion, official order or proof of an actual transaction.

When and how this form is used

Rule 109 requires an initial examination for a person seeking mine employment and a periodical examination of every mine employee every year. Form IX contains both the certificate and detailed report, followed by different initial/periodical fitness standards.

Rules 110–113 govern the examining authority, notice and report. Initial notice is at least seven days; periodical notice at least 20 days. A certificate is not valid merely because an employer has filled a medical table.

The source standards include different initial and periodical vision and blood-pressure criteria. The example is an initial record, uses actual-field hypothetical values, and does not replace the qualified authority’s interpretation of genuine tests.

Rule 114 retains medical certificates/history and occupational-dust profile during employment and for five years afterwards, with the prescribed transfer of records. This is sensitive medical material, not a public employee dossier.

The completed fields

Certificate — hypothetical initial examination

Prescribed field / section	Completed fictional entry
Certificate / employee / mine / role	[synthetic DEMO-IME-01]; Ravi Kumar, employee DEMO-M01; Illustration Quartz Mine (fictional), Example Village, Example Tehsil, District Illustration, Rajasthan 302001; surface stores worker; initial examination 20 October 2026
Selected opinion branch	Hypothetical examining-authority entry: medically fit for mine employment on the assumed full records. Unfit/re-examination alternatives N/A. No real fitness certificate or entitlement to mine work is issued
Examining authority / execution	Fictional qualified examining practitioner trained for the prescribed occupational-health role; name [fictional], actual registration not invented; place District Illustration; Unsigned fictional illustration; no actual signature, DSC, seal, certification, approval or acknowledgement

Annexure — completed fictional examination values

Prescribed field / section	Completed fictional entry
Identification / development / body measurements	Ravi Kumar (fictional), male, born 15 June 1996, 30 years; employee DEMO-M01; 5 Example Street, Example Village, District Illustration, Rajasthan 302001; identification mark: small old scar on left forearm (fictional); good development; 170 cm, 68 kg; photo/thumb impression/signature not reproduced
4. Eyes	Right/left distant acuity 6/6 with correction; no organic disease, night blindness, colour-test abnormality or squint in the hypothetical record; no genuine ophthalmology report supplied
5. Ears and audiometry	Hearing right/left normal in the hypothetical record; organic disease none; air and bone conduction right/left normal; actual audiometry annexure required
6. Respiratory / chest / spirometry	No abnormal auscultatory entry in scenario; inspiration 94 cm, expiration 89 cm. FVC predicted 4.0 L/performed 3.9 L/97.50%; FEV1 predicted 3.3 L/performed 3.2 L/96.97%; FEV1/FVC predicted 82.50%/performed 82.05%/99.46% of predicted; PEF predicted 480/performed 470 L/min/97.92%
7. Circulation / heart	BP 120/78 mm Hg; pulse 72/min; S1/S2 normal, no added sound in assumed record; ECG and initial-examination echocardiogram no abnormality in the fictional report index
8. Abdomen / ultrasound	No tenderness, enlarged liver/spleen or tumour in the hypothetical record; initial whole-abdomen ultrasonography no abnormality; actual report required
9. Nervous system / exposure checks	No fits/epilepsy, paralysis, mental-health or neurological abnormality in the hypothetical record; superficial/deep reflexes and peripheral circulation normal; vibration syndrome absent. No manganese exposure assumed: all exposure-specific behavioural/speech/tremor/coordination/emotional-change rows N/A
10–15. Locomotor / skin / hydrocele / hernia / teeth / speech	No abnormality in the fictional record; no hydrocele or hernia; dentition and speech adequate in the assumed assessment
16. Blood / sugar / lipids / kidneys	Hb 14 g/dL, TLC 7,000/µL, differential 60/30/7/2/1%, ESR 8 mm/hour, platelets 250,000/µL; fasting glucose 90, PP 120 mg/dL; HbA1c 5.4%; cholesterol 170, triglyceride 110, HDL 50 mg/dL; urea 25 mg/dL, creatinine 0.9 mg/dL
16. Urine / stool / other investigations	Urine pH 6.0, albumin and glucose absent; stool routine no abnormality in scenario; sputum AFB N/A, not a food-handling role; initial haemoglobin electrophoresis no sickle-cell disease/trait in hypothetical record; bilirubin 0.8/0.2 mg/dL, SGOT 24/SGPT 25 U/L; urine delta-ALA N/A, no lead exposure assumed
17. Chest radiograph / ILO classification	Hypothetical ILO entry profusion 0/0; pneumoconiotic opacities absent, type N/A. No actual X-ray or ILO classification by a real clinician represented
18–20. Other abnormality / tests / specialist	None in the assumed record; additional tests and specialist opinion N/A on selected facts; the actual examining authority determines what is necessary

Reports, copies and retention

Prescribed field / section	Completed fictional entry
Annexures / execution	Audiometry, spirometry, ECG, echocardiogram, ultrasound, laboratory and chest-radiograph reports listed in a hypothetical index only; genuine reports not fabricated. Examining authority’s seal/signature not executed
Copy route	Employee copy; mine owner/agent/manager copy; examining-authority retained copy, following rule 113

Supporting records and reconciliation

Actual employee identity and notice, qualified examining-authority appointment/training, genuine full test reports and occupational/exposure history, applicable initial/periodical standard and authentic certificate copies.

Worked calculation: FVC 3.9/4.0 = 97.50%; FEV1 3.2/3.3 = 96.97%; actual FEV1/FVC 3.2/3.9 = 82.05%. Fictional values do not themselves certify fitness.

Official source and version

Official Gazette, OSHWC (Central) Rules 2026, Form IX, PDF pages 258–267

OSHWC Code 2020: governing Act; the form is read with its applicable section and 2026 Central Rule

Download the official source pages containing this form. Adjacent prescribed forms can share a source page; use the heading and rule identified above.

The Central Rules have their stated jurisdiction. The corresponding appropriate-government rules and any later amendment must match the real establishment and event.

Practical questions

Can I submit the sample as my own completed form?

No. Replace the fictional facts with accurate records, use the competent filing or record-keeping route described above and complete genuine signatures or certifications where required.

What makes the example specific to this form?