Application form for Authorized Certifying Surgeon
Self signedpassport size
latest
photograph
of the
Candidate
To,
The Director,
Industrial Safety & Health,
5th floor, Commerce Centre,
Tardeo, Mumbai
Pin-400 034.
Sub. : Application for Authorized Certifying Surgeon
Respected Sir,
With respect to above mentioned subject, I am submitting following information :
1. Name of Applicant :
2. Name of District Applied for
Authorized Certifying Surgeon :
3. Address of Clinic / Hospital :
(Phone / Mobile)
4. Educational Qualification :
5. Experience regarding health check-up :
of Industrial Workers
6. Experience regarding working as :
Authorized Certifying Surgeon, if any
7. Facilities & equipments available at :
the Clinic / Hospital for Industrial
workers health check-up
8. Available Staff in clinic & their :
qualification
9. Whether working as a Factory Medical :
Officer at present
Date : Signature :
Place : Applicant’s Name :
Attach following documents :
1) Affidavit on stamp paper (Rs. 20/-)
2) Attested documents regarding educational qualification
3) Demand draft of Rs. 10,000/- (Rupees Ten Thousand only) as application fee in favour of “Director
Industrial Safety & Health, Mumbai” payable at Mumbai.
4) Monthly Report in format regarding work done as Authorized Certifying Surgeon in past.
5) Experience certificates regarding health check-up of Industrial workers.
Syllabus for First Aid Training of Industrial Workers
1. Introduction to Factories Act, 1948 (Provisions relating to First Aid
Appliances, Ambulance room, Medical Examination, Accident
Reporting etc.)
2. Introduction to First Aid.
3. Action at Emergency.
4. The practice of First Aid.
5. Resuscitation.
6. Disorder of respiratory system.
7. Disorder of Circulation.
8. Wound & Bleeding.
9. Disorders of consciousness.
10. Bone, Joint & Muscle injury.
11. Burns & Scalds.
12. Effect of heat & cold.
13. Foreign bodies.
14. Poisoning.
15. Dressing & Bandages.
16. Handling & transport of injured.
17. Emergency First Aid.
Duration of Training Course – 3 Days.