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

Universal Citation: 8 CA Code of Regs C
Current through Register 2024 Notice Reg. No. 38, September 20, 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.

___________________________ ___________________________ ___________________________
CityDatePhysician'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.

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