RS

DA

pr13

_381

Winding engine driver’s health certificate

Mines Safety and Inspection Regulations 1995 — regulation 11.12

Place Date

I have examined (full name in block letters)

I certify that this person is not suffering from deafness, defective vision, epilepsy, disease of the heart, diabetes or other infirmity to any such extent as would, or would be likely to, render this person unfit for his or her duties or liable to become suddenly incapable of controlling his engine.

Any defects in vision, hearing or physical condition to be stated.

Eyesight Right eye Left eye Both eyes

Without glasses 6 / 6 /

With glasses

Colour vision is

Hearing is

Blood pressure

Further remarks

Signature of examinee (to be made in the presence of medical practitioner)

Address

Signature of medical practitioner

Address

Winding engine driver’s certificate

Regulation 11.12 — Winding engine drivers to have medical examinations(1) This regulation does not apply to

(a) a person who is exempted from holding a winding engine driver’s certificate; or

(b) the operator of a hoist.

(2) Each person in charge of a winding engine at a mine must attend before a medical practitioner for a medical examination

(a) before the person first takes charge of the winding engine;

(b) either

(i) in the case of a person who has attained 65 years of age, before the expiration of 6 months from the day on which the person last had a medical examination under this regulation; or

(ii) in any other case, before the expiration of 12 months from the day on which the person last had a medical examination under this regulation;

and

(c) at such other times as the medical practitioner may require.

Penalty: See regulation 17.1.

(3) A person who receives a medical examination as required under this regulation must forward to the manager of the mine within 7 days after receiving that examination, a medical certificate that complies with subregulation (4).

Penalty: See regulation 17.1.

(4) The medical certificate must

(a) be in a form approved for that purpose by the Board of Examiners; and

(b) state that the person is not suffering from deafness, defective vision, epilepsy, disease of the heart, diabetes or other infirmity to such an extent as would, or would be likely to, render the person unfit for his or her duties or liable to become suddenly incapable of controlling his or her engine.

(5) A person must not operate a winding engine if a medical practitioner has certified that the person is not in a fit state of health to operate such an engine.

Penalty: See regulation 17.1.

(6) An employer at a mine must not knowingly employ a person who contravenes this regulation.

Penalty: See regulation 17.1.

/ /

6 /

6 / 6 / 6 /

No.: Class: