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EMP M/s Fortune Stone Ltd., Chhatarpur (MP) 1 ENVIRONMENT MANAGEMENT PLAN (EMP) Introduction The environment management plan has been prepared for subject opencast /fully mechanized mining operation for Granite with capacity of 20000 m 3 per year. The EMP includes formulation, implementation and monitoring of environmental protection measures during operation of the project. The EMP list out all these measures for the mining activities. The EMP is prepared keeping in view of all possible strategies oriented towards impact minimisation. The main objectives of EMP are given below: To establish the present environmental scenario considering the other activities in the study area. To anticipate the impacts of existing and proposed mining operations on the environment. To prepare a detailed action plan for implementation of mitigative measures. To suggest preventive and mitigative measures to minimise adverse impacts and to maximize beneficial impacts. To suggest a post operational monitoring programmes of mitigative measures to ensure the quality of environment To suggest the formation of a core group responsible for implementation of protective measures and regular monitoring of such implementation To prepare a capital cost estimate and annual recurring cost for Environmental Management Plan Through environment plan is under execution for existing operation; however it is required to provide further strength for effectiveness. Mitigation measures at the source level and an overall management plan are elicited so as to conserve the environment. It is observed that quarry area is recorded as degreased forest land. Two quarries are adjacent to the subject area and ten another quarries are located in the 10 km radius. One village and one surface water bodies have also been observed near to quarry area. Implementation of EMP is should consider the above stated tenure. The environmental attributes, which are likely to be affected, are land use, topography, water resources, soil, air quality, socio-economic status, ecology and public health.

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EMP

M/s Fortune Stone Ltd., Chhatarpur (MP) 1

ENVIRONMENT MANAGEMENT PLAN (EMP)

Introduction

The environment management plan has been prepared for subject

opencast /fully mechanized mining operation for Granite with capacity

of 20000 m3 per year. The EMP includes formulation, implementation

and monitoring of environmental protection measures during operation

of the project. The EMP list out all these measures for the mining

activities. The EMP is prepared keeping in view of all possible strategies

oriented towards impact minimisation. The main objectives of EMP are

given below:

To establish the present environmental scenario considering the

other activities in the study area.

To anticipate the impacts of existing and proposed mining

operations on the environment.

To prepare a detailed action plan for implementation of mitigative

measures.

To suggest preventive and mitigative measures to minimise

adverse impacts and to maximize beneficial impacts.

To suggest a post operational monitoring programmes of mitigative

measures to ensure the quality of environment

To suggest the formation of a core group responsible for

implementation of protective measures and regular monitoring of

such implementation

To prepare a capital cost estimate and annual recurring cost for

Environmental Management Plan

Through environment plan is under execution for existing operation;

however it is required to provide further strength for effectiveness.

Mitigation measures at the source level and an overall management plan

are elicited so as to conserve the environment.

It is observed that quarry area is recorded as degreased forest land. Two

quarries are adjacent to the subject area and ten another quarries are

located in the 10 km radius. One village and one surface water bodies

have also been observed near to quarry area. Implementation of EMP is

should consider the above stated tenure.

The environmental attributes, which are likely to be affected, are land

use, topography, water resources, soil, air quality, socio-economic

status, ecology and public health.

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EMP

M/s Fortune Stone Ltd., Chhatarpur (MP) 2

Environmental Management System

The management as a part of its environment policy declared its

responsibility and commitment to protect the environment and to ensure

the public safety. To realise the implementation of its environmental

policy, project management should give proper structure to

environmental management system.

Air Environment

The potential sources of air pollution arising from the existing is

observed from excavation of mineral, waste dumps, haul roads and

transportation of mineral in the vicinity. Air pollution caused by mining

and associated activities can be classified into the following categories:

Gaseous pollutants (Nitrogen Oxides, Sulphur Dioxide and Carbon

Monoxides); and

Particulate Matter.

Forever mitigative measures suggested for air pollution control are based

on the baseline ambient air quality monitoring data. It is desirable that

air quality should be monitored on a regular basis to check it vis-à-vis

the standards prescribed by CPCB and in cases of non-compliance,

appropriate mitigative measures has also been adopted.

Dust control measures

Dust is the major pollutant generated from the mining operations. Dust

is also generated during handling and transportation of the material.

The environmental control measures, which has been taken up are

existing as well as proposed to control the fugitive dust released during

the granite production are given below:

a) Haulage road & Dumps:

During the mining of granite for enhanced capacity the predicted value

reveals that the maximum incremental short term 24 hourly ground

level concentrations of particulates is 3.18 g/m3. Following measures

has been taken to mitigate the effect of granite mining operation over

ambient air environment:

Frequent Water spraying has already been carried out on the

haulage roads, services road & dump area and same practice will

continue in future also.

Considering the location of village (north east direction), dumping

has been done in North West and south direction.

Over burden dumps will not be left active for longer period and will

be used for reclamation purposes.

Over burden dumps has been temporary stabilized with legumes

and grasses to prevent the erosion of soil and to arrest the dust

emission during windy days.

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EMP

M/s Fortune Stone Ltd., Chhatarpur (MP) 3

Water has already been sprayed over the muck pile and dumps to

reduced the dust generation;

Dust mask has already been provided to all workers.

Regular maintenance of vehicles and machines has been carried

out in order to control emissions;

Cutting tools for granite have been used with the spray of water to

reduce the dust emission.

During the drilling of granite block, water has been sprayed, so

reduced the dust emission

Haulage of overburden/mine waste to the siding has been done by

dumper. After excavation, mineral has been transported to the

port or Indian customers at Bombay or Jaipur by hired dumper

(24t capacity). The approach road from lease area to PWD road is

about 0.2km, which is kuchha road; however no habitations have

been observed along the said kachha road. Dust generation due to

transportation will be for limited period and extent to small area.

Water spraying has already been carried out frequently and same

will be continued.

Emission Sources and Control Options

Operation or source Control options

a) Mining Operations

Loading Water wetting

Hauling (emissions from roads)

Water wetting, Soil stabilization, Traffic

control.

All above measures is expected to be continue in future

Controlling of CO levels

The concentration of CO in ambient air was less than 1 ppm at all the

air quality monitoring locations. Expected increase in the CO

concentration is very low as CO emissions from mining operations are

negligible as compared to other pollutants. Heavy and light vehicles are

the major sources of CO in the mine. All vehicles and their exhausts

would be well maintained to reduce the CO concentrations.

Controlling of NO2 levels

The source of NO2 would be due to vehicular emissions. This can be

controlled by proper maintenance and servicing of vehicles.

Occupational health & safety measure wrt air environment

All the above precautions has been adopted to prevent dust generation

at site and to be dispersed in the outside environment. However, for the

safety of workers at site, dust masks have also been provided. Dust

masks is help to prevent preventing inhalation of PM thereby reducing

the risk of lung diseases and other respiratory disorders. Regular health

monitoring (ones in a year) of workers has also been carried out.

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EMP

M/s Fortune Stone Ltd., Chhatarpur (MP) 4

Noise Environment

The main source of noise in mining activity is drilling, blasting,

excavation & transportation of ore. As there are one village observed

within 500m ranges, noise level has been insignificant as the operations

are of intermittent nature. The prevailing day and Night noise levels at

Village reported are between 46.8-50.4 dBA and 35.6-36.3dBA

respectively. Although the ambient noise level monitoring carried out in

and around the existing quarry shows that ambient noise levels are well

within the stipulated limits of CPCB. Blasting and drilling has been

required for mining activity. In order to further control the noise levels in

the work zone following measures are adopted:

A) Drilling

1. Hydraulic drills has been used for drilling;

2. All moving parts are properly lubricated; and

3. Non-moving parts are properly fastened.

B) Blasting

1. Blast shall be well designed and arranged in such a way that only one

or two holes are blasted at a time with the use of short delay

detonators in combination with sequential blasting machine and also

maintaining the charge per delay;

2. Maximum noise shall be generated during secondary blasting.

Primary blasts shall be so designed that boulder generation will be

minimum. Hydraulic Rock Breaker shall be used for breaking

boulders instead of conventional pop shooting;

3. Explosives shall be blasted in confined stage or optimum stemming

column is maintained during charging of holes;

4. Blasting shall be done between 12 noon’s to 4 pm when temperature

inversions are not likely to be there and air density is less.

5. At least three rows of trees are planted to reduce propagation of noise

and dust due to blast outside the lease;

6. No blasting shall be done when the sky is clouded because cloud

cover can cause reflection of pressure wave back to the ground level

at some distance from the blast; and

7. Electric detonators shall be used instead of the detonating fuse as

trunk line.

Mitigation Measures to Reduce Ambient Noise Levels

The following control measures are being adopted to keep the

ambient noise levels well below the limits:

A thick tree belt shall be being provided in phased manner around

the periphery of the mine to screen the noise;

Trees shall be planted on both sides of roads used for transport of

men and material;

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EMP

M/s Fortune Stone Ltd., Chhatarpur (MP) 5

Proper maintenance has been done of noise generating machinery

including the transport vehicles; and

Silencers have been provided to modulate the noise generated by

machines.

Installation of noise generating machinery, strictly in compliance

with the recommendations of the manufacturers. This would

ensure an installation free from vibration and exhaust leaks which

are also major contributors to increased noise levels

Provision of insulating caps and aids at the exit of noise source on

the machinery.

Use of damping materials such as thin rubber sheet for wrapping

the worn places of compressors, generators etc.

Shock absorbing techniques to reduce impact

Apart from above, the formation of internal dump and green belt

development will also muffle the noise to a great extent.

Regular maintenance of machines and vehicles have been carried

out regularly. All moving parts of machine have been properly

lubricated; Non-moving parts of machine have been properly

fastened

Acoustic treatment for rotating equipments

Measures to Protect Workers from High Noise Levels

The following measures have been taken to protect the workers from

exposure to higher noise levels:

i. Noise is considered as an occupational hazard. Blasting is an

occasional and impulsive event, which needs to be carried out in

an isolated manner.

ii. The workforce working at the mining face, where high noise level is

expected, has been provided with protective device for

occupational safety.

iii. Compulsory use of personnel protective equipment (PPE) such as

ear plugs for the workers

Water Environment

There is no water course in the lease area. The main drainage of the area

is through seasonal Nalla which is in south west at 100m distance. The

water table in the quarry area varies from 20m to 22m whereas mining

will be done up to avg. 15m depth thus ground water table will not touch

during conceptual period. Surface water source will not be affected in

the quarry area due to small scale, opencast mining. Rainwater may get

accumulated in the working pit. The pumped out water will be used to

fill the village pond, which is used by villagers. The quality of discharged

water must be ensured after settling tank before draining at pond. Water

requirement of the project is estimated is 21kl per day, which will be met

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EMP

M/s Fortune Stone Ltd., Chhatarpur (MP) 6

from existing bore well, pit water and through tanker. Following

measures has been taken to avoid accumulation of water:

1. Pump has already been installed to lift accumulated rain water from

working pit.

2. Garland drain has already been made along the waste dumps which

help to restrict/retain the loose particles. Depth & length of garland

drain is observed 0.50m and 1000m respectively.

3. Garland drain has also been made along the slop of hill along the

village side. Length & depth of garland drain is observed approx

1000m and 2.5m

4. It must be ensured that silt content in the mines discharged is

minimum.

5. It must be ensured that quality of drinking water for the worker is

hygienic.

Land Environment and solid waste management

The original topography of the part of area will further be affected due to

the expansion operation. It has been observed that 16.80ha area has

already been excavated during past mining. During the life of mine total

20.75 ha areas will be excavated and same will be reclaimed using mine

waste, OB and soil. During the conceptual period, about 2355115 m3

mine waste will be generated and same will be dumped at outside of the

quarry area. Weathered granite/mine waste will be used for backfilling

and reclamation purpose. During the mine life about 2075ha area will be

reclaimed and afforested. Lessee has already been developed the 125ha

land by afforestation, which will be continue in future also. Presently

1.80ha and 3.0ha area has been covered by waste dump within and

outside of quarry area respectively. Existing waste dump has been

stabilized by grasses and shrubs. Garland drain has already been made

along the waste dumps which has been restrict/retain the loose

particles. Depth & length of garland drain has been observed 0.50m and

1000m respectively, which will be increased with the paces of further

mining.

Biological Environment

Since there are no notified endangered species in the area, which will be

effected due to the mining activities, therefore the biological environment

will not have significant impact due to proposed activity. The impact on

the biological environment due to amount of dust generation is

minimised by well-developed green belt in and around mining lease area.

The green belt development not only functions as foreground and

background landscape features resulting in harmonizing and

amalgamating the physical structures of the mines with surrounding

environment, but also acts as pollution sink as indicated above. Thus,

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EMP

M/s Fortune Stone Ltd., Chhatarpur (MP) 7

implementation of afforestation program is of paramount importance. In

addition to augmenting present vegetation, it will also check soil erosion,

make the ecosystem more complex and functionally, stable and make

the climate more conducive. The plantation matrix should be adopted for

the green belt development includes pits of 0.3m x 0.3m x 0.3 m size

with the spacing of 2.0 m x 2.0m.

Selection Criteria of plant species for Green Development Plant

The selection of plant species for the development depends on various

factors such as climate, elevation and soil. Area falls under the tropical

region and thus the local species should be selected. Following criteria

may be taken for selection of species.

The species should be fast growing.

The species should form a dense canopy.

As far as possible, the species should be indigenous and locally

available

Soil improving plants (Nitrogen fixing, rapidly decomposable leaf

litter).

Plant Species for Mine Area and its Boundary

• Acacia nilotica

• Leuceana leucocephala

• Albizzia species

• Morus indica/alba

• Acacia auriculiformis

• Prosopis species

• Azadirachta indicata

• Syzygium cuminii

• Annona squamosa

• Tamarindus indica

• Bauhinia variegata

• Terminelia arjuna

• Butea monosperma

• Zizyphus species

• Cassia festula

• Carissa species

• Dalbergia sisoo

• Feronia species

• Erythrina indica

• Phylanthus species

• Ficus bengalensis

• Madhuca species

• Ficus religiosa

• Magnifera species

• Grewia species

• Leuceana leucocephala

Plantation Schedule

A stage-wise comprehensive afforestation program is prepared and shall be

implemented. The locations of the proposed greenbelt along with area of the

green cover are given in the conceptual plan.

Afforestation plan

ENVIRONMENT IMPACT & MANAGEMENT: Ecology: Stage Wise Cumulative Plantation

REQUIREMENTS OF PLANTS FOR AFFORESTATION/RECLAMATION

Year Unworked

area green

belt

Outside dumps

(reclaim)

bench of pit village side Total

Area

(Ha)

Tree

s

Area

(Ha)

Trees Area

(Ha)

Trees Area

(Ha)

Trees Area

(Ha)

Trees

Present 0.1 100 - - - - - - 0.1 100

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EMP

M/s Fortune Stone Ltd., Chhatarpur (MP) 8

1st to 5th - - - - - - 0.5 750 0.5 750

5th to conceptual

period

0.386 580 20.75 31125 - - - - 21.136 31705

Total 1.386 680 20.75 31125 - - - - 21.736 32555

Occupational, Health and Safety

To avoid any adverse affects on the health of workers due to dust &

noise, sufficient measures have been provided in the mining project.

These may include:

Provision of rest shelters for mine workers with amenities like

drinking water, fans, toilets etc.

Provision of personal protection devices to the workers;

Dust suppression of haul road; and

First-aid facilities in the mining area.

The management will carry out periodical audit of safety and health

with view to ascertaining the effective implementation of policy.

Regular medical examination will be conducted for the employees.

Protective measures for Occupational Safety & Health hazards has also

been implemented, so that such exposure can be kept within permissible

level. Evaluation of health of workers has been made through pre-

designed format, for chest X-ray, Audiometry, Spirometry Vision testing

(Far & Near vision, colour vision and any other ocular defect) ECG,

during pre placement and periodical examinations.

Medical Check-up Schedule

Total Blood Picture Once a Year

Blood Pressure and Heart Function Once in 6 Months

Skin Check Up Once a Year

ENT Once a Year

Chest X Ray If needed

Spirometry Once a Year

Audiometry Once a Year

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EMP

M/s Fortune Stone Ltd., Chhatarpur (MP) 9

CONFIDENTIAL ENTRY MEDICAL

EXAMINATION

I hereby authorize any of the doctors, hospitals or clinics mentioned in this form to provide the Medical Service with copies of all my medical records so that the Organization can take action upon my application for employment.

I certify that the statements made by me in answer to the questions below are, to the best of my knowledge, true, complete and correct, I realize that any incorrect statement of material omission in the medical information form or in

any other required by the Organization renders a staff member liable to termination or dismissal.

Date : (dd/mm/yy)

Signature

Pages 1 and 2 are to be completed by the candidate

Family Name (In Block

Capitals)

Given Names Maiden Name (For Women Only) Sex

M [ ] F [ ]

Address (Street, Town, District or Province, Country) And Telephone Date Of Birth (Day/Month/Year)

NATIONALITY

Position Applied For (Describe Nature Of Work)

Telephone Birthplace

DUTY STATION

Present Marital Status Single [ ]

Married [ ] Date : (Dd/My/Yy) ----------------- Divorced [ ] Date : (Dd/My/Yy) ----------------- Separated [ ] Date : (Dd/My/Yy) ----------------- Widowed [ ] Date :

(Dd/My/Yy) ---------------------

Have you ever undergone a medical examination for any other agency ? ____________________________________________

Have you ever been employed by this company or any other agency ? ______________________________________________ If so, please stae when, where and for which organization: ________________________________________________________

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M/s Fortune Stone Ltd., Chhatarpur (MP) 10

FAMILY HISTORY

Relative Age (if still alive)

State of Health (If still alive,

present state: if

deceased cause of death)

Age at death Have members of your family

had the following

illnesses or disorders?

Yes No Who?

Father High Blood Pressure

Mother Heart Disease

Brothers Diabetes

Sisters Tuberculosis

Spouse Asthma

Children Cancer

Epilepsy

Mental Disorders

Paralysis

TO BE COMPLETED BY THE OFFICIAL REQUESTING

THE MEDICAL EXAMINATION

TO BE COMPLETED BY THE DIRECTOR OF THE

MEDICAL SERVICE

Name of the Official : Comments :

Department or Unit :

Date : Date : (dd/mm/yy) Signature:

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M/s Fortune Stone Ltd., Chhatarpur (MP) 11

VERY IMPORTANT : Please indicate the recruiting Agency or Organization:

Each question requires a specific answer (yes, no, date etc.); to leave a blank or draw a line is not sufficient. If the questionnaire is not fully completed and enquires are therefore needed, time may be lost.

1. Have you suffered from any of the following diseases or disorders? Check yes or no, If yes, state the year-

YES Date

NO YES Date

NO YES Date

NO YES Date

NO

Frequent sore throats

Heart and blood vessel

disease

Urinary disorder

Fainting spells

Hay fever Pains in the heart region

Kidney trouble

Epilepsy

Asthma Varicose veins

Kidney stones

Diabetes

Tuberculosis Frequent Back Pain Gonorrhoea

Pneumonia Ulcer of stomach or duodenum

Joint problems

Any other sexually transmitted

disease

Pleurisy Jaundice Skin disease Tropical

diseases

Repeated

bronchitis

Gall Stones Sleeplessness Amoebic

dysentery

Rhueumatic

fever

Hernia Any nervous

or mental disorder

Malaria

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M/s Fortune Stone Ltd., Chhatarpur (MP) 12

High blood

pressure

Haemorrhoids Frequent

headaches

2) Are you being treated for any condition now ? ________________ Describe : _________________________

________________________________

3) Have you ever coughted up blood ? ___________________________________________________________

4) Have you ever noticed blood in your stools ? ________________In your urine ? ________________ Give details:

________________________________________________________________

5) Have you ever been hospitalized (hospital, clinic,etc.)? ____________________________________________ Why,

where and when ? _____________________________________________________________________

6) Have your ever been absent from work for longer than one month through illness ? ________________ If so,

when? ________________________________________________________________________________ And for what

illness ? _______________________________________________________________________

7) Have your had any accidents as a result of which your are partially disabled? ________________ If so, what

and when? ________________ ______________________________________________________________ Do you have

any other disability? _____________________________________________________________

8) Have your ever consulted a neurologist, a psychiatrist or a psychoanalyst? _____________________________

_________________________________________________________________________________________

9) Are you taking any medicine regularly? ________________If so, which? ______________________________

_________________________________________________________________________________________

10) Have you gained or lost weight during the last three years? ________________ if so, which? _________

_________________________________________________________________________________________

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M/s Fortune Stone Ltd., Chhatarpur (MP) 13

11) Have you ever been refused life insurance? ________________________________ If so, state reason:

_________________________________________________________________________________________

12) Have you ever been refused employment in health grounds? ________________ If so, state reason:

________________

13) Have your ever received or applied for a pension or compensation for any permanent disablity?

________________ Degree ? ________________________________ Please give details: ________________

________________________________________________________________________________

14) Have you ever stayed in any other country? ___________________________________________if so, for how

long? ________________________________________________________________

15) Have you in the past suffered from any condition which prevented travel by air? ________________

________________________________________________________________________________________

16) Do you consider yourself to be in good health ? ________________Do you have full work capacity ?

________________ ________________________________________________

17) Do you smoke regularly? [ ] Yes [ ] No. If so, what do you smoke? [ ]

Cigerettes [ ] Pipe [ ] Cigars For how many years have your smoked? ________________ How

much per day? ________________________________________________________________

18) Daily consumption of alcoholic beverages: ___________________________________________________

19) Has any doctor or dentist advised you to undergo medical or surgical treatment in the foreseeable

future? ________________________________________________ ____________________________________ Give

details: _____________________________________________________________________________

20) Give any other significant information concerning your health: ________________________________

_________________________________________________________________________________________

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M/s Fortune Stone Ltd., Chhatarpur (MP) 14

21) What is your occupation? ________________________________Indicate at least three posts you have

occupied: ________________________________________________________________________________

22) List any occupational or other hazards to which you have been exposes:

________________________________ ________________________________

23) Have you ever been rejected for military service for medical reasons? ______________________________

________________________________________________________________________________

24) FOR WOMEN

Are your periods regular? [ ] Yes [ ] No. Do you take contraceptive pills [ ] Yes [ ] No If so, for how

many years have

Are they painful ? [ ] Yes [ ] No. You been doing sio? ____________________Have you ever been treated for a

gynecological

Do you have to stay in bed when they come [ ] Yes [ ] No. complaint? [ ] Yes [ ] No.

If so for how long? ______________________Date of your last period: _______________ If so, which?

___________________________________________________________________________________________________________

TO BE COMPLETED BY THE EXAMINING PHYSICIAN

GENERAL APPEARANCE Height cm. Weight: kg.

Skin: Scalp:

SIGHT, MEASURED VISUAL ACUITY

Gross vision Right Left Pupils: Equal? Regular?

Vision with spectacles Right Left Fundi (if necessary):

Near vision Right Left Colour vision:

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M/s Fortune Stone Ltd., Chhatarpur (MP) 15

With correction Right Left

Right Left

HEARING

(test by whispering

Right Normal: Sufficient: Insufficient:

Left Normal: Sufficient: Insufficient:

Ear drum Right: Left:

NOSE- MOUTH-NECK Nose: Pharynx: Teeth:

Tongue: Tonsils: Thyroid:

CARDIOVASCULAR SYSTEM Pefipheral arteries

Pulse rate: Auscultation: - carotid:

Rhythm: Blood

pressure:

-posterior tibial:

Apex beat: Varicose

veins:

- dorsalis pedis:

Electrocardiogram-Please attach tracing

RESPIRATORY SYSTEM

Thorax:

Breasts RIGHT LEFT

DIGESTIVE SYSTEM Spleen:

Abdomen: Hernia:

Liver: Rectal examination:

NERVOUS SYSTEM Plantar reflexes

Papillary reflerxes:

- To light: Motor functions:

-On accommodation: Sensory functions:

Patellar reflexes: Muscular tonus:

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M/s Fortune Stone Ltd., Chhatarpur (MP) 16

Achilles reflexes: Romberg's sign:

MENTAL STATE

Appearance: Behaviour:

LABORATORY The results of all the following investigations must be included except where marked "if indicated"

Urine: Albumin Sugar Microscopic

Blood:

Haemoglobin:

%

grams/I Leucocytes:

Haemoglobin: %

Differential count (if indicated):

Erythrocytes: Blood sedimentation rate:

Blood chemistry:

Sugar: Urea or creatinine:

Cholesterol: Uric acid:

Serological test for syphilis: Please attach laborartory report

Stool examination:

COMMENTS (Please comment on all the positive answers given by the staff member and summarize the abnormal findings):

CONCLUSIONS(Please state your opinion on the physical and mental health of the candidate and fitness for the proposed post):

The examining doctor is requested before sending this report to verify that the questionnaire, pages 1 and 2 of this form, has

been fully completed by the candidate and that all the results of the investigations required are given on the report. Incomplete report are a major source of delay in recruitment.

Name of the examining physician (in block capitals): Signature:

Address: Date: (dd/my/yy)

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M/s Fortune Stone Ltd., Chhatarpur (MP) 17

CONFIDENTIAL PERIODIC MEDICAL EXAMINATION

For recruitment do not use this

form

Periodic Examination [ ] Extension[ ] Reassignment [ ]

End of Service [ ]

Pages 1 and 2 are to be completed by the staff member

FAMILY NAME(IN BLOCK CAPITALS)

GIVEN NAMES

MAIDEN NAME (FOR WOMEN ONLY)

SEX

M [ ] F [ ]

ADDRESS (STREET, TOWN, DISTRICT OR PROVINCE, COUNTRY) AND TELEPHONE

DATE OF BIRTH (day/month/year)

NATIONALITY

EMPLOYMENT HELD

SINCE FAMILY SINCE THE LAST EXAMINATION:(MARRIAGE, BIRTH, DEATHS, DIVORCE: GIVE THE DATES)

YEARS OF SERVICE

DEPARTMENT OR UNIT

OFFICE OR DIVISION/SECTION LAST COMPLETE MEDICAL EXAMINATION Date: (d/m/y) Place :

DUTY STATION (CITY AND COUNTRY)

A. INTERIM HISTORY - Since your last examination-

1. Indicate the illnesses or accidents which you have had, stating their length- Give the place of hospitaliztion if

applicable-

2. Do you consider that your health is altogether satisfactory? if not, for what reason?

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M/s Fortune Stone Ltd., Chhatarpur (MP) 18

3. Have you been examined by: Your own doctor? [ ] Yes [ ] No A specialist? [ ] Yes [ ] No

if so, when and for what reason?

4. Have your consulted: A neurologist? ? [ ] Yes [ ] No A psychiatris? [ ] Yes [ ] No A psychoanalyst? [ ]

Yes [ ] No If so, when and for what reason?

5. Are you under medical treatment at present? If so, state treatment followed:

6. Have members of your family had any serious health problems? ? [ ] Yes [ ] No If yes, give detailsL:

7. Please give any additional information that might help the examining doctor:

8. Name and address of your own doctor:

TO BE COMPLETED BY STAFF MEMBER TO BE COMPLETED BY THE DIRECTOR OF THE MEDICAL SERVICE

Place: Medical Classification: 1a 1b 2a 2b

Comments: Date(d/m/y):

Signature:

Date: (d/m/y) Signature:

VERY IMPORTANT : Please indicate the Agency or Organization concerned L:

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M/s Fortune Stone Ltd., Chhatarpur (MP) 19

B. PRESENT HEALTH - Each question requires a specific answer (yes, no, date, etc.); to leave a blank or draw a

line is not sufficient. If the questionnaire is not fully completed and enquiries are therefore needed, time may be

lost.

YES

Date

NO YES

Date

NO yes

Date

NO Yes

Date

No

Frequent sore throats

Heart and blood vessel

disease

Urinary disorder

Fainting spells

Hay Fever Pains in the

heart region

Kidney trouble Epilepsy

Asthma Varicose veins

Kidney Stones Diabetes

Tuberculosis Frequent

indigestion

Back pain Gonorrhoea

Pneumonia Ulcer of

stomach or duodenum

Joint

problems

Any other

sexually transmitted disease

Pleurisy Jaundice Skin disease Tropical diseases

Repeated bronchitis

Gall stones Sleeplessness Amoebic dysentery

Rheumatic feber

Hernia Any nervous or mental

disorder

Malaria

C. DAILY HABITS

1. Do you smoke regularly? ( ) Yes ( ) No

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M/s Fortune Stone Ltd., Chhatarpur (MP) 20

If so, what do you smoke? ( ) Cigarette ( ) Pipe ( ) Cigars

For how many years have you smoked

How much per day?

2. Daily consumption of alcoholic beverages:

3. Recreation:

What kind now?

How often?

D. FOR WOMEN STAFF ONLY.

1. Do you take contraceptive pills? ( ) Yes ( ) No

2. When did you last visit a gynecologist?

For what reason?

3. Any pregnancies since last examination?

4 Date of menopause (if applicable): (d/m/y)

LABORATORY Except by prior agreement, only the investigations mentioned are done at the Organization's expense

Urine: Albumin Sugar Microscopic

Blood:

Haemoglobin: %

grams/I Leucocytes:

Haemoglobin: %

Differential count (if indicated):

Erythrocytes: Blood sedimentation rate:

Blood chemistry:

Sugar: Urea or creatinine:

Cholesterol: Uric acid:

Serological test for syphilis: Please attach laborartory report

Stool examination:

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M/s Fortune Stone Ltd., Chhatarpur (MP) 21

COMMENTS (Please comment on all the positive answers given by the staff member and summarize the abnormal findings):

CONCLUSIONS(Please state your opinion on the physical and mental health of the candidate and fitness for the proposed

post):

The examining doctor is requested before sending this report to verify that the questionnaire, pages 1 and 2 of this form, has been fully completed by the candidate and that all the results of the investigations required are given on the report. Incomplete

report are a major source of delay in recruitment.

Name of the examining physician (in block capitals): Signature:

Address: Date: (dd/my/yy)

All first aid facilities has already been provided in the quarry office

All the medicines prescribed by doctors has been provided to the employees at free of cost by the

management.

The working personnel has already been given the following appropriate personnel protective equipments.

Industrial safety helmets.

Ear plugs.

Industrial safety shoes with steel toe.

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M/s Fortune Stone Ltd., Chhatarpur (MP) 22

Socio economic Measures

Socio-economic survey was been conducted in 10 villages of the study

area out of total 36 villages. The selected villages are Kathara, Marwa,

Ranmau, Devikhera, Andhiyara Bari, Parsaniyan, Ratanpara, Raja

purwa, Devpura and Mureri of the study area. M/s Fortune Stone Ltd.

under its CSR plan identifies the needs of the surrounding villages and

has developed a social management plan to benefit the surrounding

areas. Thus the surrounding villages have been benefited from the

existing mining activity. M/s Fortune Stone Ltd. has already been given

the employment to local peoples in the existing quarries i.e. approx 145

numbers as per the qualification and skill. M/s Fortune Stone Ltd. has

already carried out number of welfare activities in the area like:

Samuhik Kanya Vivah: year 2009

Deeping of local pond (Kathara)

Free Medical Camp (Eye & Dental check-up) at Lovekush nagar –

26.12.2011

Construction of Hospital Building at Kathara

Provision of Doctor and Compounder in Hospital (Kathara)

Contribute to Local Area Development Fund

Free drinking water supply facility to nearby village by Tanker

Proposed activity

Free Medical Camp

Free drinking water supply facility to nearby village by Tanker