California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4 - Division of Industrial Safety › Subchapter 20 - Tunnel Safety Orders › Appendix C

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
Department of Industrial Relations Division of
					 Occupational Safety and Health
MEDICAL EXAMINATION FOR HOISTING
					 ENGINEERS
(To be sent to the project manager)
Name of Applicant _____________________Address
					 _________________________
Employer _______________________ Address
					 ___________________________
Record of Past Employment
Employer _______________________Address
					 ___________________________
Absence from work during past 6 months and reasons
					 ___________________________
Total years' experience as hoisting engineer
					 ______________________________ Licensed ______________________________ Where
					 ___________________________
Date of last medical exaimination, if any
					 ___________________________
Place of birth ________________________Date
					 ___________________________
Marital Status ___________________________
Are you in good health? ___________________________
Have you had problems with:
Vision? ____________________ Fainting spells?
					 ____________________ Dizzy Spells? ____________________ Heart trouble?
					 ____________________ Epileptic Seizers? ___________________________
Alcohol/drugs? ______________________________ Have you a
					 first-aid certificate? ______________________________
Year issued? _______________________________
By whom __________________________________________________
					 I certify that all my answers to the above are correct and true and that I have
					 also read the "Orders for Hoist Engineers" in the Mine Safety Orders.
Date ___________________________
___________________________
Signature of Applicant
Physician's Report
1. Age ____________________ Weight
					 ______________________________ Height ______________________________
Temperature _________________________ Blood pressure
					 ___________________________
2. Vision: Right eye ______________________________ Left
					 eye __________________________________________________ Color Perception
					 __________________________
3. Hearing: Right ear
					 ____________________________________________________________ Left ear
					 ___________________________
4. Nose and throat: Normal
					 _______________________________________________________ Abnormal
					 ___________________________
5. Chest: Expiration
					 ___________________________________________________________ Inspiration
					 ___________________________
6. Heart: Rhythm ______________________________ Size
					 ______________________________ Ausculation ______________________________ Pulse
					 ___________________________
7. Abdomen: Scars or hernia
					 ___________________________
8. Spine ________________________________________
					 Deformities __________________________________________________ Rigidity
					 ___________________________
9. Genito-urinary system ___________________________
10. Urinalysis ___________________________
11. Hemorrhoids ______________________________ Varicose
					 veins ___________________________
12. Defects of joints, bones or muscles
					 ___________________________
13. Does applicant appear to be addicted to stimulants or
					 narcotics? ___________________________
14. Posture: Excellent
					 ________________________________________ Good
					 ________________________________________ Fair
					 ________________________________________ Bad ___________________________
15. Reflexes: Patella
					 ________________________________________ Rhomberg
					 ______________________________ Rabinski ______________________________
					 Coordination ___________________________
16. Nervous or composed
					 ____________________________________________________________ Tremors
					 ___________________________
17. Mental Agitation? ___________________________ Medical
					 Reasons for rejection, if any ___________________________ Date
					 __________________________________________________ Physician's Name
					 __________________________________________________ M.D.
					 ___________________________
Address_________________________
..........................
Detach and post in the hoist
					 house
Hoist Engineer's Medical Examination
The medical examination of Mr.
					 __________________________________________________ leads me to believe he is
					 physically able to assume the duties of a hoisting engineer as of this
					 date.
___________________________
___________________________
___________________________
City
Date
Physician's Signature
1. Repealer
					 and new appendix and new NOTE filed 3-5-96; operative 4-4-96 (Register 96, No.
					 10).
2. Editorial correction establishing separateHISTORIES for
					 appendix (Register 2003, No. 28).
Note: Authority cited: Sections
						142.3 and
						7997, Labor
						Code. Reference: Sections
						142.3 and
						7997, Labor
						Code.