admission the mental Hospital/MansikArogyashala is not absolutely necessary for ……………………..months/days. Date Seal Signature Name FORM OF REGISTER TO BE MAINTAINED IN HOSPITALS WHERE MENTAL PATIENT HAVE BEEN ADMITTED SI. Name Nature of Name Date of Nature Duration Date of Remarks. No. of the of the of of or of worker mine retention partial e. the recovery doctor Scheme no11. FORM – „A‟ APPLICATION FOR TREATMENT OF MINE/BEEDI/CINE WORKERS SUFFERING FROM CANCER 1. Name in full of worker. 2. Name & Address in full of mine/beedi establishment. 3. Name of patient. 4. Age and relationship with the worker. 5. Date of his/her employment and the total continuous service. 6. Designation of the nature of his/her employment.
admission the mental Hospital/MansikArogyashala is not absolutely necessary for ……………………..months/days. Date Seal Signature Name FORM OF REGISTER TO BE MAINTAINED IN HOSPITALS WHERE MENTAL PATIENT HAVE BEEN ADMITTED SI. No. Name of the worker Nature of Name of the mine Date of Nature of Duration of retention or partial recovery Date of of the doctor Remarks. Scheme no11. FORM – „A‟ APPLICATION FOR TREATMENT OF MINE/BEEDI/CINE WORKERS SUFFERING FROM CANCER 1. Name in full of worker. 2. Name & Address in full of mine/beedi establishment. 3. Name of patient. 4. Age and relationship with the worker. 5. Date of his/her employment and the total continuous service. 6. Designation of the nature of his/her employment. e.
forms_no4.%20.docx