FORM S
(See rule 29L)

Report of medical re-examination by Appellate Medical Board
**(To be issued in triplicate)
We do hereby certify that we have examined Shri/Shrimati* ........................, Nature of employment ....................., Serial number from Form B Register................ of................... mine, who has been declared medically unfit for
(a)  *Any employment in mine.
(b) *Any employment below ground.
(c) *Any employment or work ...................................
(Specify in detail)
As a result of a medical examination under rule 29B. Our Report is given overleaf.
We consider that—
1. He/She* is medically fit for any employment in mine.
2. He/She* is suffering from ........................ and is medically unfit for
(a) *Any employment in mine, or
(b) *Any employment below ground, or
(c) *Any employment or work .........................................
(Specify in detail)
3. He/She is suffering from ........... and should get this disability cured/controlled* and should be again examined within a period of ............ months. He/she will appear for re-examination 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/her duties during this period.
(Signature of members of Appellate Medical Board)
Place : 1. ..................... (Convenor)
Date : 2. ................ 3. ..................
REPORT OF THE APPELLATE MEDICAL BOARD
Annexure to certificate No.....................................as result of Medical examination identification mark:
On .........................................
Left thumb impression of the candidate
1. General Development: Good/Fair/Poor
2. Height Cms.
3. Weight Kg.
4. Eyes.
Distant vision (with or without glasses)
Visual acuity
(ii) Any organic disease of eyes.
*(iii) Night blindness.
Right eye ................... Left eye....................
*(iv) Colour blindness.
(v) Squint.
(*To be tested in special cases)
5.  Ears:
(i) Hearing ................................... Right ear ..................... Left ear ....................
(ii) Any organic disease.
6. Respiratory system.
Chest measurement:
(i) After full inspiration ............. cms.
(ii) After full expiration ............. cms.
7. Circulatory system:
Blood pressure.
Pulse.
8. Abdomen:
Tenderness.
Liver.
Spleen.
Tumour.
9. Nervous system:
History of fits or epilepsy.
Paralysis.
Mental health.
10. Locomotor 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.
Place : Signature of the Appellate Medical Board.