APPENDIX-A

DECLARATION BY THE OFFICIAL TO BE EXAMINED FOR SHAPE CATEGORISATION

Please record your answer
1 Where you examined for any major ailment or hospitalized
during last one year
2 Are you a Patient of :
a. Hypertension (High Blood Pressure)
b. Isehaemic heart disease ?
c. Diabetes Mellitus?
d. Chronic cough/Br. Asthma/COPD?
e. Epilepsy (Fits)?
f. Persistent Headache
g. Mental instability?
3. Have you suffered from Giddiness at any time ?

4. Have you suffered from chest pain/Palpitation

5. Did you ever suffered from Tuberculosis?
6. Your (a) Appetite
(b) Sleep
7. Smoking habit (if yes, no of cigarettes per day).
8. Alcohol intake (if yes, average quantity per day )
9 Any accident/injury/Major Surgery undergone so far ?
10. Have you been transferred recently or under order of transfer?
If so your
a. Pervious Unit
b. New Unit.

It is further certified that the above facts stated by me are true to my best knowledge and belief. I
have not suppressed any fact concerning my health condition ever in past and as is at present.

PLACE : SIGNATURE :
DATED : NAME :
IRLA/F.NO. :
DESIGNATION :
UNIT :
 APPENDIX-“C”

MEDICAL EXAMINATION PROFORMA FOR OFFICER AND MEN IN C.P.M.F

01. Name :
02. IRLA/Force No. :
03. Age :
04. Sex :
05. Height (Cms). :
06. Weight (Kg) :
07. Chest (Not for ladies :
Body mass Index : -On Expiration
-On ful Inspiration
08. Abdominal girth :
09. Trans-trochanteric girh :
10. Ratio (8/9) :
S PSYCHOLOGICAL ASSESSMENT AS LAID DOWN
i) Any past history of psychiatric illness, if so details:
ii) Any history of breakdown/outburst or taking wrong decisions, Indecisiveness leading to
public
reaction or castigation of civil authority.
iii) History of any alcoholic/drug abuse.
iv) History of Head injury /infective/ metabolic- en-cephalopathy.
v) Objective Psychometric scale if any applied and result there of :
CATEGORISATION: S-1/ S-2 /S-3/ S-4/ S-5
H HEARING
i) Normal in both ears v) Auroscopy-
ii) Moderate defect in one ear. vi) Ronnie’s Test-
ii) Partial defect in both ears. Vii) Weber’s Test-
iv Any other combinations. Viii) Audiometry ( if indicated)
CATEGORISATION: H-1 / H-2/ H-3

Contd.. P/No.02..
 : 02 :
A APPENDAGES
i) Upper limb
ii) Lower limb
iii) Any loss/ infirmity in any joint or part must be indicated in detail.
CATEGORISATION: A-1(U), A-2 (U), A-3 (U)
A-I (L), A-2 (L), A-3 (L)
P PHYSICAL
General Examination:
Distance covered in 12 minutes run/ walk (meters)
Body built : :BP (mm Hg) :
Tongue : : Puise /mt :
Anaemia : : Temp © :
Cyanosis : :
Icterus : : Respiration :
Oedema :
Clubbing :
Koilonychia :
Lymph glands palpable. : Tonsils :
JVP : :Teeth/Denture :
Thyroid : Throat :
Spleen : : Liver :
C.V.S. : : E.C.G.: Required after age of 45 year
S1 : : Blood Sugar : If applicable
S2 : Urine exam : In all cases
: Hb % : In all cases
Murmur if any :
R-System: : Any deformity of chest: : Percussion
Breath sounds Adventitious sounds
C.N.S. : Higher functions: : Memory (Recent & Remote )
Intelligence
Personality
Orientation(time, place & Person
Cranial Nerves
 Contd.. P/No.03..

: 03 :
Meningeal Sign if any-
Motor System Nutrition of muscles Wasting-
Tone
Coordination
Abnormal movement/ fasciculation
Power
DTR
Plantar- Abdominal & Cremasteric refl-
Cerebellar Sign Gower’s Sig
Sensory System-
Reflexes- Romberg’s sign- SLR Finger- Toe
Test
Skull & Bone
Abdomen: General: Any mass palpable any other abnormality
Piles/ Fissure- Fistula- Prolapse rectum
INVESTIGATION:
1. HB % :
2. Urine examination for all ages. :
3. ECG after age of 45 year : Blood sugar if Applicable and for all
above 45 years.
4. Any other investigation as deemed necessary by examining Medial Board (i.e. X-Ray
Chest
Lipid Profile Glycosylated Hb etc.

I agree/ Don’t agree to undergo HIV test signature.

CATEGORISATION: P1 P2 P3

‘’E’’ Factor (Eye sight/ Vision)

(a) Distant Vision-
(b) Near Vision-
(c) Colour Vision –
(d) Field of Vision
(e) Any other Pathology
(f) IOL
CATEGORISATION : E1 E2 E3

FINAL CATEGORISATION

ADVICE/EMPLOYABILITY
RESTRICTION(S) IF ANY

(NAME OF MEDICAL OFFICER) (BOARD MEMBERS) ( DESIGNATION/UNIT)

 APPENDIX-“D”

PROFORMA FOR CERTIFICATE TO BE PRODUCTED BY AN APELLANT

CHALLANGING THE FINDINGS OF AMA/MEDICAL BOARD REQUESTING FOR
REVIEW

I Dr. ……………………………………………… certify that I have examined

Shri/Smt/Kumari………
…………………………………………………………… aged………………
years……………………………
of Unit …………………………………………………… who has been categorized in …………………
due to
…………………………………………………………… After careful, examination and investigation ,
it is opined that S/ He is not suffering from……………………………………………………. To arrive
at this decision. I have examined the relevant of medical documents and conducted necessary
investigations.

Seal
Date:

Signature of Medical Officer/Civil Surgeon

Name/Designation………………………..
Reg. No. ………………………………….
Hospital: …………………………………
STATION STATION

DATE

1
UNIT

DATE DATE OF
ADMISSION

HEIGHT (cms)

PLACE
DATE OF

2
WT (Ks) DISCHARGE

CHEST
DURATION
WAIST/HIP RATIO
3
DISEASE

Pulse & BP
DISEASE
TABLE-1I

TABLE-1II
(PSYCHOLOGICAL)
TABLE-1 (10 PAGES)

H
(HEARING) PARTICULAR
S/DISEASE/DI
4
REMARKS

SABILITY
RECORD OF ADMISSION IN HOSPITAL

A
(APPENDAGES)
CATEGORISATION

CATEGORISA
P
ANNUAL MEDICAL CHECK UP AND CATEGORISATION
TION
(OHYSUCAK CAOACUTY)

E
DISABILITY/NEEDS ATTEND. C/REST FOR MORE THAN SEVEN DAYS

5
RECORD OF OPD TREATMENT OF DISEASES WHICH LEAVE RESIDUAL

(EYE SUGHT ) SIG OF

MEDICAL
SIGNATURE

FINAL CATEGORISATION OFFICER

REASON IN BRIEF IF
ATEGORY IS DOWN GRADED
 TABLE-IV
RECORD OF VACCINATION TAKEN
Primary vaccination (e.g. BCG): Taken Not taken
Tetanus toxoid: Date Last Taken:
Hepatitis-B : Taken Not
Any other optional Vaccination ( Please specify)

APPENDIX” B”
INDIVIDUAL HEALTH CARD

HEALTH CARD

(FORCE NAME & MONOGRAM)

IRLA/FORCE
NO………………………………………………………………………………………….

RANK:
……………………………………………………………………………………………………..

NAME :……………………………………………………………………………………………………
UNIT :……………………………………………………………………………………………………..

E-MAIL MESSAGE

TO : THE DIG/AP (E& NE) HQRS KOLKATA

INFO : THE CASO ASG KOLKATA
: THE CASO ASG BANGALORE
FROM: CASO ASG TEZPUR
---------------------------------------------------------------------------------------------------
NO.E- 42099/CISF/TEZ/MED/08 - 2023 DATED 25/11/2008
---------------------------------------------------------------------------------------------------
MEDICAL CATEGORY UNDER SHAPE SYSTEM (.) KINDLY REFER TO DIG//AP (E&NE)
HQRS KOLKATA E-MAIL MESSAGE NO.E-42099/ADM.II/MED/(E &NE)/08-3966 DATED
20/11/2008 (.) IN THIS CONNECTION IT IS INTIMATED THAT ANNUAL MEDICAL
EXAMINATION 2008 UNDER SHAPE CATEGORY IN RESPECT OF THE PERSONNEL AVAILABLE
IN THE UNIT HAVE BEEN COMPLETED EXCEPT 10 (TEN) PERSONNEL i.e. 09 ( NINE)
PERSONNEL DEPLOYED ON I.S. DUTY AT ASG KOLKATA AND 01 (ONE) CONSTABLE
ON I.S. DUTY AT ASG BANGALORE (.) THE CASO ASG KOLKATA HAVE ALREADY BEEN
REQUESTED TO DETAIL THE PERSONNEL FOR AME VIDE THIS OFFICE LETTER OF EVEN NO.
1697 DATED 16/09/2008 AND NO. 1850 DATED 06/11/2008 AND ASG BANGALORE VIDE
EVEN NO. 1578 DATED 29 /08/2008 AND NO. 1952 DATED 06/11/2008 (.) FOR CASO ASG
KOLKATA AND BANGALORE : REQUEST KINDLY DETAIL THE PERSONNEL OF ASG TEZPUR
WHO ARE ON I.S. DUTY FOR AME AND INTIMATE THE PROGRESS FOR ONWARD
SUBMISSION TO DIG/AP (E&NE) HQRS KOLKATA AT AN EARLIEST PLEASE (.) MSG OVER
--------------------------------------------------------------------------------------------------
-SD-25.11.08
 OFFICE OF THE CASO/ASSTT.COMMANDANT
CENTRAL INDUSTRIAL SECURITY FORCE
(MINISTRY OF HOME AFFAIRS)

ASG TEZPUR

NO. E-38016/CISF/TEZ/SHAPE-1 CORRS/09- Dated 16/01/2009

Sub :- INTIMATION REGARDING MEDICAL SHAPE CATEGORY.

02. it is to intimated that during the annual medical Examination of the following personnel
the medical board given the remarks as mentioned against each individual :-

(i) No. 892290756 Const. S. Gogoi - overweight more than 10 % and review
after 10 weeks
(ii) No. 892292949 Const. S. Dutta - overweight more than 10 % and review
after 10 weeks

Hence you are hereby directed to do the need full as advice the Doctors board .

CASO TEZPUR AIRPORT

& ASSTT.COMMANDANT

Distributions:-

1. No. 892290756 Const. S. Gogoi : ( through Coy Commander )

CISF Unit ASG Tezpur

2. No. 892292949 Const. S. Dutta : - do-

CISF Unit ASG Tezpur
 E-MAIL MESSAGE

TO : THE DIG/AP (E& NE) HQRS KOLKATA

INFO : THE CASO ASG KOLKATA

FROM : CASO ASG TEZPUR

------------------------------------------------------------------------------------------------------------------------------
NO.E- 42099/CISF/TEZ/MED/08 - DATED 02/01/2009
-----------------------------------------------------------------------------------------------------------------------------
MEDICAL CATEGORIZATION CLASSIFICATION BY SHAPE SYSTEM FOR THE YEAR 2008 (.)
KINDLY REFER TO DIG//AP (E&NE) HQRS KOLKATA E-MAIL MESSAGE NO.E-42099/ADM.II/MED
(FN)/(E&NE)/08-14 DATED 02/01/2009 (.) IN THIS CONNECTION IT IS INTIMATED THAT THE
REQUIRED INFORMATION AS ASKED VIDE MESSAGE UNDER REFERENCE IS AS UNDER (.)
NAME OF POSTED TOTAL NO. OF NO OF ACTION PLAN FOR LEFT OUT REM
THE ASG STRENGTH PERSONNEL PERSONNEL PERSONNEL ARKS
OF THE UNDERGONE YET TO
ASG ANNUAL UNDERGO
MEDICAL AME’08
EXAMINATION
AS POER
SHAPE SYSTEM
(1) (2) (3) (4) (5) (6)
TEZPUR 38 34 04 ALL THE 04 LEFT OUT PERSONNEL
ARE ON I.S. DUTY AT ASG KOLKATA
AND CASO ASG KOLKATA HAS
ALREADY BEEN REQUESTED TO
DETAIL THE PERSONNEL FOR AME-08

(.) FOR CASO ASG KOLKATA: KINDLY REFER TO THIS OFFICE EVEN LETTER NO. (1697) DATED
16/09/2008,(1950) DATED 06/11/2008 AND (2185) DATED 10/12/2008 ON THE ABOVE SUBJECT (.) IT
IS AGAIN REQUESTED TO DETAIL CONST S. GOGOGI ,CONST. SURESH DUTTA, CONST D. KALITA
AND CONST T. SINGSION OF ASG TEZPUR WHO ARE ON I.S. DUTY AT ASG KOLKATA FOR AME-2008
AND SENT COMPLIANCE REPORT TO DIG/AP (E&NE) UNDER INTIMATION TO THIS OFFICE PLEASE (.)
MMU (.)
-------------------------------------------------------------------------------------------------------------------

CASO ASG TEZPUR

 & ASSTT. COMMANDANT/CISF

E-MAIL / FAX MESSAGE

TO : DIG/AP (E&NE) HQRS KOLKATA

FROM : CASO TEZPUR AIRPORT

---------------------------------------------------------------------------------------------------------
NO.E-42099/CISF/TEZ/SHAPE-I(09/ 81 DATED: 15 JAN’09
--------------------------------------------------------------------------------------------------------
MEDICAL CATEGORIZATION CLASSIFICATION BY SHAPE SYSTEM FOR THE
YEAR’2008(.) KINDLY REFER TODIG/AP (E&NE) E-MAIL MESSAGE NO.E-
42099/ADM.II/MED(FN)/(E&NE)/09/ 82 DATED: 07 JAN’08 (.) AS DESIRED COMMA THE
REPORT ON THE SUBJECT MATTER PERTAINING TO ASG TEZPUR IS FURNISHED BELOW
FOR INFORMATION AND NECESSARY ACTION PLEASE(.)

NAME OF REQUIRED NO.OF NO. OF REMARKS

THE ASG TO PERSONNEL PERSONNEL YET
UNDERGO UNDERGONE TO UNDERGO
A.M.E’08 A.M.E’08 AME’08
(1) (2) (3) (4) (5)
TEZPUR 38 38 - -

MSG OVER (.)

_______________________________________________________________________
-SD-15.01.2009

CASO TEZPUR AIRPORT

& ASSISTANT COMMANDANT CISF
 E-MAIL MESSAGE

TO : THE DIG/AP (E& NE) HQRS KOLKATA

INFO : THE ADG/APS CISF HQRS NEW DELHI
FROM : CASO ASG TEZPUR
--------------------------------------------------------------------------------------------------------------
NO.E- 42099/CISF/TEZ/MED/09 - DATED 24/01/2009
---------------------------------------------------------------------------------------------------------------
STANDING MEDICAL BOARD AT CISF MEDICAL NHCC SAKET, NEW DELHI & SHCC
NISA HYDERABAD FOR THE YEAR 2009. REG. (.) KINDLY REFER TO DIG//AP (E&NE)
HQRS KOLKATA E-MAIL MESSAGE NO.( 72) DATED 23/01/2009 (.) IT IS SUBMITTED THAT
REPORT ON THE SUBJECT MATTER IN RESPECT OF CISF UNIT ASG TEZPUR MAY PLEASE BE
TREATED AS NIL (.) MSG OVER
-----------------------------------------------------------------------------------------------------------------

CASO ASG TEZPUR

& ASSTT.COMMANDANT/CISF

E-MAIL MESSAGE

TO : THE DIG/AP (E& NE) HQRS KOLKATA

INFO : THE ADG/APS CISF HQRS NEW DELHI
FROM : CASO ASG TEZPUR
--------------------------------------------------------------------------------------------------------------
NO.E- 42099/CISF/TEZ/MED/09 - DATED 24/01/2009
---------------------------------------------------------------------------------------------------------------
STANDING MEDICAL BOARD AT CISF MEDICAL NHCC SAKET, NEW DELHI & SHCC
NISA HYDERABAD FOR THE YEAR 2009. REG. (.) KINDLY REFER TO DIG//AP (E&NE)
HQRS KOLKATA E-MAIL MESSAGE NO.( 72) DATED 23/01/2009 (.) IT IS SUBMITTED THAT
REPORT ON THE SUBJECT MATTER IN RESPECT OF CISF UNIT ASG TEZPUR MAY PLEASE BE
TREATED AS NIL (.) MSG OVER
-----------------------------------------------------------------------------------------------------------------

CASO ASG TEZPUR

& ASSTT.COMMANDANT/CI
 E-MAIL MESSAGE

TO : THE DIG/AP (E& NE) HQRS KOLKATA

FROM : CASO ASG TEZPUR
---------------------------------------------------------------------------------------------------
NO.E- 42099/CISF/TEZ/MED/09 - DATED 14/09/2009
---------------------------------------------------------------------------------------------------
ANNUAL MEDICAL EMAMINATION UNDER SHAPE CATEGORY FOR THE YEAR’ 2009
(.) KINDLY REFER TO DIG//AP (E&NE) HQRS KOLKATA LETTER NO.E-31014/AP(E
&NE)/ADM.II/MEDICAL(SHAPE)/09-3149 DATED 09TH SEPT’09. (.) IN THIS CONNECTION IT IS
INTIMATED THAT THE ANNUAL MEDICAL EXAMINATION 2009 UNDER SHAPE CATEGORY IN
RESPECT OF THE PERSONNEL POSTED IN CISF UNIT, ASG TEZPUR IS EXPECTED TO BE
COMPLETED BY THE END OF SEPT’09. A LETTER WITH A LIST OF CISF PERSONNEL WHO
ARE TO UNDERGO THE SAID MEDICAL EXAMINATION AT SSB HOSPITAL HAS BEEN SENT TO
THE DIG/SSB,SALONIBARI FOR NECESSARY ACTIONS (.)MSG OVER
--------------------------------------------------------------------------------------------------

CASO/ASSTT COMMANDANT
CISF UNIT, ASG TEZPUR

Sl.No. CISF No. Rank Name Remarks

01 874380137 Insp/Exe Mithilesh Kumar Over weight
02. 884492085 HC/GD E. Mathivanan Over weight
03. 824490773 HC/GD Bhupender Singh Over weight
04 834501193 HC/GD S.N. Pandey Over weight
05. 014504530 Const. S. Biswas Over weight
06. 014505201 Const. Anup Das Over weight
07. 004690333 Const. O.O. Singh Over weight
08 883482065 W/C J Paul Raj Over weight
 PERSONNEL BIO-DATA FORM

01. CISF No..............................Rank………………Name……………………………………………………….

02. Father’s Name…………………………………………
03. Date of Initial Appointment in CISF with Rank……………………….
04.D.O.B………………………………05.Religion…………………………………..
06.Whether SC/ST/OBC/Gen…......... 07.Identification Mark…………………………………………………
08.Blood Group………………………… 09.Date of Promotion in present Rank………………………..
10. Whether direct/ optee/ Ex-Army/Deputation……………………………………………………………………
11.Date of joining in the unit………………………………12.PSL No……………………………………………..
Records of posting since joining in CISF:-
SN FROM TO Name of unit Zone

13. Education Qualification……………………………………………………………………………

14. Educational Qualification in technical, if any…………………………………………………….
15. Qualified in Basic Trg. Or Not……………………………………………………………………
16. Qualified in PCC Or Not : Const to Hc/GD………………………..
HC/GD to ASI/EXE………………….
ASI (MIN/EXE to SI (MIN/EXE)………………….
SI (MIN/EXE) to Insp (Min/Exe)…………………..
17. Identity Card No…………………………… 18. Next of Kin………………………………………….
19. Relationship………………………………
20. Any other course attended in CISF/ Army/ any other Organization
……………………………………………………………………………..
Details of family members:-
SN Name Age Relationship

Indv.Signature
Name
CISF NO
CISF Unit ASG Lilabari Airport