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    Physical Fitness Form Employment Certificate

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    Stanly stephen
    This document is a certificate of physical fitness for a minor issued by the Illinois Department of Labor. It contains personal information about the minor such as name, address, date of birth, school, and intended work. The certificate must be filled out by a physician examining the minor, including medical data like vision, hearing, physical examination results, and any remarks. The physician then approves or does not approve the minor's fitness for work based on the examination.

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    Physical Fitness Form Employment Certificate

    Uploaded by

    Stanly stephen
    75 views1 page
    This document is a certificate of physical fitness for a minor issued by the Illinois Department of Labor. It contains personal information about the minor such as name, address, date of birth, school, and intended work. The certificate must be filled out by a physician examining the minor, including medical data like vision, hearing, physical examination results, and any remarks. The physician then approves or does not approve the minor's fitness for work based on the examination.

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    This document is a certificate of physical fitness for a minor issued by the Illinois Department of Labor. It contains personal information about the minor such as name, address, date of birth, school, and intended work. The certificate must be filled out by a physician examining the minor, including medical data like vision, hearing, physical examination results, and any remarks. The physician then approves or does not approve the minor's fitness for work based on the examination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    75 views1 page

    Physical Fitness Form Employment Certificate

    Uploaded by

    Stanly stephen
    This document is a certificate of physical fitness for a minor issued by the Illinois Department of Labor. It contains personal information about the minor such as name, address, date of birth, school, and intended work. The certificate must be filled out by a physician examining the minor, including medical data like vision, hearing, physical examination results, and any remarks. The physician then approves or does not approve the minor's fitness for work based on the examination.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    STATE OF ILLINOIS

    DEPARTMENT OF LABOR
    Labor Enforcement Division
    Certificate of Physical Fitness

    As Required by Section 12, Paragraph 4, Child Labor Law of Illinois, Effective June 30, 1947

    Name________________________________ Address_______________________________________________

    School___________________________ Grade___ Birth _____________________________________________


    Place Month Day Year Proof

    Sex___ Complexion_________ Hair________ Kind of Work___________________________________________

    Employer____________________ Address_____________________________ Industry____________________

    Date Re-Examined__________________________________________________________________________
    Date Height Weight
    ___________________________________________________________________________________________
    Date Re-Examined__________________________________________________________________________
    Date Height Weight
    ___________________________________________________________________________________________
    Date Re-Examined_____________________________________________________________________________________
    Date Height Weight
    ____________________________________________________________________________________________________
    Remarks___________________________________________________________________________________

    __________________________________________________________________________________________
    NOTE: Issuing officer should fill in information at top of certificate and then have minor take certificate to examining physician for medical data returning same to
    issuing officer for permanent record; for any re-examination, use the same certificate. This form is furnished by the Department of Labor, or may be
    reproduced.

    MEDICAL DATA
    Date Examined_______________________ Age_______________________ Height___________________ Weight_______________
    Year Month
    Vision____________________________________________________ Hearing________________________________________

    Family History__________________________________________________________________________________________________

    _______________________________________________________________________________________________________________

    Physical History_________________________________________________________________________________________________

    _______________________________________________________________________________________________________________

    Examination____________________________________ Development______________Nutrition_______________________________

    Nose ____________________ Throat _________________ Ears_________________________Mouth______________________

    Neck ____________________ Heart __________________ Lungs ______________________ ChestX-Ray_________________

    Abdomen _____________________________________________ Hernia_____________________________________________

    Smallpox Vaccination _________________ Diptheria Immunization _________________ Pediculosis_____________________

    Special Examination_____________________________________________________________________________________________

    REMARKS: ____________________________________________________________________________________________________

    _____________________________________________________________________________________________________

    Approved_______________ Not Approved _______________ Signed ___________________________________________ M.D.


    Examiner

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