The Insecticides Rules, 1971

1 (a) Name, address and status of the applicant.

(b) Category of the industry - SSI/DGTD/MRTP/FERA/others.

2. Address of the premises where the manufacture will be done.

3. The common name and trade name of the insecticides which the applicant proposes to import or manufacture.
4. Whether the application is for import or for manufacture:

(i) in the case of import please state:-

1. Name and address of the manufacturer.
2. Name and address of the supplier if he is duly authorised by the manufacturer.
3. Is the insecticide registered in the country:

1. Of manufacture.
   1. From which supplies are expected to be made.

1. in the case of manufacture please state;

Whether the insecticide is meant for domestic consumption or for export or for both.

5. In the case of formulation, the sources of supply of technical grade material and its status of registration. Chemical composition.
6. (I) Kind and name of active and other ingredients and percentages of each.

(ii) Stability in storage (as per details specified by the Registration committee).

3. shelf life claim.

7. Toxicity of the products to human beings, wild life, aquatic animals toxicological data to be enclosed (as per details specified by the Registration Committee0.
8. The plant diseases, insects and other poisonous animals and weeds against which it is intended to be used. (published/authentic reports on bioefficacy of the insecticide to be enclosed as per details specified by the registration committee.
9. Instructions for storage and use including first-aid and precautionary measures which are proposed for labelling.
10. (I) ten copies of specifications for product, quality and methods of analysis for technical/ formulated compound (as applicable ) and its residues.

(ii) analytical test report for the product quality.

11. seven copies of the proposed labels and leaflets (including all printed or graphic matter which will accompany the package containing the insecticide0 as per the insecticides rules, 1971.
12. Manner of packing.
13. Particulars of fee deposited.

--------------------

1. substituted by GSR 533(E), dt. 6-8-1993.
2. Signature of the applicant With seal
   
   

   Verification
   
   I &&&&&&. S/o &&&&&&&. Do hereby solemnly verify that to the best of my knowledge and belief the information given in the application and the annexures and statements/ accompanying it is correct and complete.
   
   I further declare that I am making this application in my capacity as & and that I am competent to make this application and verify it by virtue of &. A photo/ attested copy of which is enclosed herewith.
   
   Place&&.. Signature&&&..
   
   Date&&.. with seal
   
   Note: the application form including the verification portion must be signed in case of an individual, by the individual himself or a person duly authorised by him; in case of Hindu undivided family, by the Karta; in case of a partnership firm, by the managing partner; in case of a company, by a person duly authorised in that behalf by the Board of Directors, and in any other case, by a person incharge of or responsible for the conduct of the business.]
   
   

   FORM II
   GOVERNMENT OF INDIA
   MINISTRY OF AGRICULTURE
   (Department of Agriculture)
   CERTIFICATE OF REGISTRATION OF INSECTICIDES
   [Rule 6(4)]
   
   certified that the insecticide &&&.has been registered in the name of the person/ undertaking whose particulars are specified below;
   
   1 Name of the Person/ undertaking.
   
   

2. Address.
3. Registration No.
4. Name of the insecticide.

(Brand name or trade name or chemical name of the insecticide, details thereof regarding its composition, etc.)

7. Conditions, if any.

New Delhi, the &&19.

Signature&&

Seal of Department

Conditions

 

1[FORM II-A
GOVERNMENT OF INDIA
MINISTRY OF AGRICULTURE
(Department of Agriculture and Cooperation)
CERTIFICATE OF PROVISIONAL REGISTRATION OF INSECTICIDES
[See rule 6]

3. Certified that the insecticide &. Has been registered in the name of the person / undertaking whose particulars are specified below provisionally for a period of two years effective from the date of issue:-

1. Name of person / undertaking
2. Address
3. Registration number
4. Name of insecticide

(Brand name or trade name and chemical name or trade name and chemical name of the insecticide, details of composition).

5. Conditions, if any:

(i)

(ii)

(iii)

New Delhi, the &19&

Signature

Seal of Department

FORM II-B
APPEAL UNDER SECTION 10 OF THE INSECTICIDES ACT, 1968,
TO THE CENTRAL GOVERNMENT
[Rule 7]

To,

The Secretary
Ministry of Agriculture,
(Department of Agriculture and Cooperation),
New Delhi,
Appeal No&.. of 19&.

1. Name and address of the applicant
2. Address of the manufacturing unit:
3. Name of the insecticides
4. Date of order appealed against
5. Date of communication f the order
6. Whether the appeal is within limitation period
7. Particulars of the fee deposited
8. Relief claimed in appeal
9. Address to which notice may be sent to the applicant

*Statement of Facts

*Grounds of Appeal

Signature (appellant)

*(Please give each ground in a separate paragraph and number it).

Signature (appellant)

VERIFICATION

I&&.S/o &. The appellant, do hereby verify that what is stated above is true to the best of my knowledge and belief:

Date:

Place:

Signature (Appellant).

1. The appeal must be preferred in duplicate and must be accompanied by a copy of the order appealed against.
2. The form of appeal, grounds of appeal and the form of verification must be signed incase of an individual by the individual himself or a person duly authorised by him; in case of Hindu Undivided family by the karta; in case of partnership company, by the managing partner; in the case of company, by a person duly authorised by the Board of Directors and in any other case, by the person incharge or responsible for the conduct of the business.]

1[FORM III
APPLICATION FOR THE GRANT OF LICENCE TO MANUFACTURE INSECTICIDES
[Rule 9]

1. Name, address and status of the applicant:
2. Address of the premises where the manufacturing activity will be done:
3. Name of the insecticides with their registration number and date for which manufacturing licence is applied for (enclose copies of certificate of registrations duly signed by the applicant).
4. Whether any registration is provisional, if so give particulars

Name of insecticides Registration No. Date

1.

2.

3.

5. Details of full time expert staff connected Name Qualification Experience

with the manufacture and testing of the 1.

Insecticides in the above unit: 2.

3.

6. Whether all the facilities required under
7. Chapter VIII of the rules have been provided, Give full details in a separate sheet.
8. Particulars of the fee deposited:

Signature of the applicant

Verification

I&. S/o&&.. do hereby solemnly verify that to the best of my knowledge and belief the information given in the application and the annexures and statements accompanying it, is correct and complete.

I further declare that I am making this application in my capacity as&. And that I am competent to make this application and verify it by virtue of & a photo/ attested copy of which is enclosed herewith.

Date:

Place:

Signature with seal.]

FORM IV
APPLICATION FOR RENEWAL OF LICENCE
TO MANUFACTURE INSECTICIDES
[RULE 9(1)]

1. I / We&& of &. Hereby apply for the renewal of the licence to manufacture insecticides on the premises situated at& (Licence No. and date to be given).
2. The other details regarding the manufacture of the insecticide continue to remain the same.
3. [1] particulars of the fee deposited.]
4. the licence is enclosed herewith.

Date&.

Signature&&

2[Verification

I && S/o&&.. do hereby solemnly verify that what is stated above is true and correct to the best of my knowledge and belief.

-------------

1. substituted by GSR 533(E), dt. 6.8.1993.
2. inserted by GSR 533(E), dt. 6.8.1993

----------

I further declare that I am making this application in my capacity as &.. designation) and that I am competent to make this application andverify it, by virtue of &. A photo/ attested copy of which is enclosed.

Date

Place

Signature with seal

*If there is any change in the details of manufacture or conditions of licence subject to which the licence is required to be renewed, the same may be indicated here.

FORM V
[Rule 9(3)]

1. Number of licence and date of issue&&.
2. &.. of &&.is hereby granted a licence to manufacture the following isecticides on the premises situated at&.. under the direction and supervision of the following expert staff.

1. Expert staff (name)&&
2. Name of insecticides&.

3. The licence authorises the sale by way of wholesale dealing by the licensee and storage for sale by the licensee of insecticides manufactured under the licence.

1[PROVIDED such sales are made from or storage is done in the factory premises.]

4. The licence shall be in force for a period of &.years from the date of issue.
5. The licence is subject to the conditions stated below and to such conditions as may be specified in the rules for the time being in force under the Insecticides Act, 1968.

Date:

Signature&..

Designation

Seal of the Licensing Officer

Conditions

1. This licence and any certificate of renewal shall be kept on the approved premises and shall be produced for inspection at the request of an Insecticides inspector appointed under the Insecticides act 1968 or any other officer or authority authorised by the licensing officer.
2. Any `change in the expert staff named in licence shall forthwith be reported to the licensing officer.
3. If the licensee wants to undertake during the currency of the licence to manufacture for sale of sale of additional insecticides, he should apply to the licensing officer for the necessary endorsement in the licence on payment of fee of rupees&& for every category of insecticides.
4. [1]. An application for the renewal of a licence shall be made as laid down in rul 11.]
5. [2] the licensee shall comply with the provisions of the insecticides act 1968, and the rules made thereunder for the time being in force.]
6. [3] The licensee shall obtain ISI mark certificate from Bureau of Indian Standard within three months of the commencement of the manufacture.
7. No insecticides shall be sold or distributed without ISI Mark Certification.]

FORM VI
APPLICATION FOR THE GRANT OF LICENCE TO SELL, OR EXHIBIT FOR SALE OR DISTRIBUTE INSECTICIDES
[Rule 10(1)]

To,

The Licensing Authority,

State of&&.

1. Full name and address of the applicant
2. Is the applicant a newcomer? 9say "yes" or "no")
3. If yes, the names of the principals, if any, whom he represents.
   

(4)[***].

1. I enclose a certificate from the principals whom I represent or whom I intend to represent and the source/ sources from which insecticides will be obtained.
2. 4[***].
3. Situation of the dealr's premises where the insecticide will be (a) stored; and (b) sold.
4. The names of insecticides in which the applicant desires to carry on business.
5. Full particulars of licences issued in his name by other state Government, if any, in their area.
6. I have deposited the licence fee.

7. Treasury Challan No&&..
   
   

   Sub-Treasury&&..
   
   

8. Declaration:

1. I / We declare that the information given above is true to my / our knowledge and belief, and no part thereof is false.
2. I / We carefully have read the terms and conditions of the licence and agree to abide by them.

Name and address of the applicant's in block letters.

Date

Place.

Signature of a applicant.

Remarks by the licensing authority.

-----------

1. substituted by GSR 474(E), dt. 24-07-1976.
2. Inserted by GSR 474(E) ,dt 24-7-1976
3. Conditions 6 and 7 inserted by insecticides (Iind Amendment) rule 1999, dt. 2005. 1999.
4. Omitted by GSR 533(E) , dt. 6-8-1993.

1[FROM VI-A
[Rule 10(3A)]
APPLICATION FOR THE GRANT OF LICENCE TO STOCK AND USE RESTRICTED INSECTICIDES(S) FOR COMMERCIAL PEST CONTROL OPERATIONS(S)

To,

The Licencing Authority,

&&&&&&&&&&

1. 1. Full name of the applicant (Block letters)
   2. Address:

9. 1. Registered Office

(ii) Zonal Office

(iii) Premises for which application is made

1. 1. Is the applicant already in business or newcomer
   2. Qualifications of responsible technical person
   3. (i)Educational Qualification (ii) training in pest control operations
      
      (iii) Experience in using restricted insecticide (s) (attach proof in respect of claims)
      
      
   4. If in the trade, give full particulars of the names of restricted insecticides(s) handles and categories fo operations undertaken, the period and the place(s) at which the trade was carried on.
   5. Quantity(s) of each restricted insecticide in possession on the date of application (Give details of place (s) where it is stored).
   6. Details of persons engaged or proposed to be engaged (Attach separate sheet, duly authenticated)
   7. Details of safety applications available along with antidotes and all other facilities required under chapter will be stored for use.
   8. Situations of the branch offices and depots where the restricted insecticide (s) will be stored for use.
   9. Name (s) of restricted insecticides (s) which the applicant desires to use.
   10. Category (s) applied for.
   11. Particulars of the fee(s) deposited.
   12. Whether technical expertise approved by the plant protection adviser to the Government of India for undertaking pest control operations Attach Proof).
   13. Whether permission obtained from Plant Protection Adviser to the Government India for undertaking fumigation (attach Proof & validity).

Signature of the applicant

Verification

I &&&& S/o&&& do hereby solemnly verify that to the best of my knowledge and belief the information given in the application and the annexure and statements accompanying it is correct and complete.

I further declare that I am making this application in my capacity as&.. and that I am competent to make this application and verify it, by virtue of &.. a photo or attested copy of which is enclosed herewith.

Date

Place

Signature with seal

FROM VI B
[Rule 10(3A)]

Application for renewal of licence to stock and use of restricted insecticides for commercial pest control operations(s).

To,

The Licensing Authority,

State&&&&&&&..

I / We hereby apply for renewal of the licence to stock and use of restricted insecticides for categories; I, II and III under by the Licensing Authority and allotted licence desired to be renewed was granted by the licensing authority and allotted licence No. && on the day of &..29&.

2. State of Change, if any in:-

1. category of operation
2. expert staff
3. restricted insecticides used
4. premises of stocking
5. address including of branch offices
6. whether any new branch / unit has been opened after grant or renewal of licence
7. any other change.

1. Particulars of fee deposited
2. Give latest details of persons engaged (attach separate sheet duly authenticated)

Signature of the applicant

Verification

I &&&S/o &&.. do hereby solemnly verify that to the best of my knowledge and belief the information given in the application and the annexures and statements accompanying it, it correct and complete.

I further declare that I am making this application in my capacity as (Designation
) and that I am competent to make this application and verify it by virtue of a photo / attested copy of which has already been submitted.

Signature with seal

Date

Place

FORM VI-C
[Rule 10(3A)]

licence to stock and use restricted insecticide(s) for commercial pest control operations

1&&&&& is hereby licenced to stock restricted insecticides viz&&. On the premises situated at&& and carry out commercial pest control operations subject to the conditions specified below and to the provisions of the insecticides act, 1968 and the rules thereunder.

2. Licence shall be in force from &&. To &&&..
3. Conditions , if any

(i)

(ii)

(iii)

Date:

Licence No&&..

Licensing Authority seal]

1[FORM VI-D
PRINCIPAL CERTIFICATE
[Rule 10(4-A)(I)]

Name and address of the manufacturer Principal certificate No.

Date

---------------------

1. inserted by insecticides (IInd amendment ) rules, 1999.dt. 20.5.1999.

We have insecticide manufacturing licences for our factories as given below:-

Sl. No.	Name & Address of the Manufacturing premises	Licence No.	Date	Valid upto	Name & address of the Licensing Authority
1	2	3	4	5	6

This is to certify that M/s&&& have applied for grant of licence (Form VI)/ renewal of Licence (Form VII) to sell, stock or exhibit for sale or distribution of insecticides as per sub-rule (1) of rule 10 of the insecticides rules, 1971. We authorise them to sell, stock or exhibit for sale or distribution of the following insecticides in wholesale/ Retail in&& Taluka/District/State.

Sl. No.	Common Name of Insecticide	Trade mark of the insecticide	Registration No.	Date

As per sr. no. 5 of the Form VI the above dealer will obtain our insecticides from the following source /sources

Sl. No.	Name of Source(s)	Detailed address of the source(s)	Licence No. & Date	Licence valid upto	Detailed address of the premises where source(s) are stocking insecticides
1	2	3	4	5	6

The dealer to whom this principal certificate has been issued will purchase our insecticides from the source / sources stated above and if he purchases our insecticides from sources other than those stated above then it would be a contravention of the insecticides act, 1968 and rules made thereunder.

This principal certificate is valid upto&..

Date

Place:

Company's seal

Signature (Authorised Signatory)

Designation

Detailed address

I shall obtain the insecticides shown in the principal certificate from the source / sources which are stated above. I am aware that if, I obtain these insecticides from source/ sources other than those stated above, this would be contravention of the insecticides act, 1968 and rules made thereunder.

Date

Place

Dealer's seal

Signature

Name:

Designation

Address of the Dealer

Dealers Licence No and Date

(if issued for renewal of licence)

copy submitted to the concerned licensing Authority

[F. No. 19-3/96-PP.I]

P.D. Sudhakar, jt. Secy.

Note:- the principal rules were published in the Gazettee of India, vide number GSR 1650, dated 11^th October, 1971 and subsequently amended vide GSR 533(E) dated 6-8-1993, and GSR 379(E) dated 2-798.]

FORM VII
APPLICATION FOR RENEWAL OF THE LICENCE TO SELL, STOCK OR EXHIBIT FOR SALE OR DISTRIBUTE INSECTICIDES
[Rule 10(1)]

To

The Licensing Authority

State of &&

I / We hereby apply for renewal of the licence to sell, stock or exhibit for sale or distribute insecticides under the name and style of&& the licence desired to be renewed was granted by the licensing authority for the state of &.. and allotted licence No&& on the day of &.19&&..

The situation of the applicant's premises where the insecticides are/ will be-

1. stored and (b) sold

(i) I /We hereby declare that the situation of my / our premises where the insecticides are stored, and (b) sold, as stated below:

1. 1. (b)

(ii) the insecticides in which i/We am/ are carrying on business and the name of the principals whom I / we represent are as stated below:

full name and address of the applicant in block letters&&&&..

date

place

signature of applicant(s).

FORM VIII
LICENCE TO SELL, STOCK OR EXHIBIT FOR SALE OR DISTRIBUTION OF INSECTICIDES
[Rule 10(4)]

1&&&&.. is hereby licensed to sell, stock or exhibit for sale or distribute by retail, insecticide&.. on the premises situated at&.. subject to the conditions specified below and to the provisions of the insecticides act, 1968 and the rules thereunder.

1. licence shall be in force from&&& to&&&&..

1[3***]

date

Licence No&&&

Licensing Authority

Seal

Conditions:

1. the licence shall be displayed in a prominent place in a part of the premises open to the public.
2. The licence shall comply with the provisions of the insecticides act, 1968, and the rules made thereunder for the time being in force.
3. [1] no insecticides shall be sold or distributed except in packages which are or may be approved by the Indian standards Institution from time to time.

3-A. if the licensee wants to sell, stock or exhibit for sale or distribute any additional insecticides during the currency of the licence he may be apply to the licensing officer for issuance of separate licences for each insecticide on payment of the prescribed fee.]

3[4. An application for the renewal of a licence shall be made as laid down in rule 11.]

"Triplicate"

FORM IX
REPORT OF INSECTICIDE ANALYST
[RULE 24(3)]

1. Name of the insecticide inspector from whom received&
2. Serial No. and date of insecticide inspector's memorandum&..
3. Number of sample&..
4. Date of receipt&..
5. Name of the insecticide purporting to be contained in the sample&..
6. Conditon of the sales on the package&.
7. Result of test or an analysis with protocols of test applied&&&.
8. Date&&&.

Insecticide analyst.

----------------

1. Omitted by GSR 533(E), dt. 6.8.1993.
2. Substituted by GSR 5333(E),dt. 6-8-1993
3. Inserted by GSR 474(E), dt. 24-7-1975.

FORM X
ORDER UNDER SECTION 21 (D) OF THE INSECTICIDES ACT, 1968, REQUIRING A PERSON NOT TO DISPOSE OF ANY STOCK IN HIS POSSESSION
[Rule 30]

whereas I have reason to believe that the stock of &&& in your possession, detailed below, is being distributed, sold or used in contravention of the provisions of section&& of the insecticides act, 1968 or && of the insecticides rules, 1971.

I hereby require you under section 21(1) (d) of the said act, to stop the distribution, sale or use of the said stock for a period of&& days from this date.

Date&..

Details of stock of insecticides formulation.

1.

2

3

4

5

6

insecticide inspector

seal.

Date

FORM XI
FROM OF RECEIPT FOR THE SEIZED INSECTICIDES
[RULE 32]

Receipt for stock of insecticide seized under section 21(1) (d) of the insecticides act, 1968.

The stock of the insecticide detailed below has this day been seized by me under the provisions of sections 21(d) of the insecticides act, 1968 from the premises of &.. situated at&&..

Details of the insecticide seized are;

(a)

(b)

(c)

(d)

insecticide Inspector

Date

Official Stamp.

FORM XII
INTIMATION TO ERSON / LICENSEE FROM
WHOM SAMPLE IS TAKEN
See rule 33]

To ,

&&&&&&&&.

&&&&&&&&..

&&&&&&&&.

I have this day taken from the premises of &.. situated at&& samples of the insecticide specified below for the purposes of test or analysis.

Date

Insecticide inspector.

Details of sample taken.

Date

Insecticide Inspector.

1[FORM XIII
REGISTER OF SALES MADE TO BULK CONSUMERS, INSECTICIDES WISE
[Rule 15]

Sl. No.	Date	Name of the insecticides with its strength and brand name	Name of the manufacturer	Batch no.	Date of expiry	Name of the purchaser with full address	*licence no. of purchaser	Qty. sold size no. of qty. of packs the sold pack	Remarks

• in case of bulk consumer give number and ate of the order.

------------------

1. substituted by GSR 533(E), dt. 6-8-1993.

FORM XIV
MONTHLY RETURN OF SALES OF INSECTICIDES MADE TO THE BULK CONSUMERS OF THE STATE OF &. FOR THE PERIOD FROM&&.. TO&. 19&..
[RULE 15]

Sl. No.	Name of the insecticides with its brand name strength and type of formu- lation	Manufactured by	Batch no.	Date of expiry	Name of the purchaser with full address	*licence no. of purchaser	Size of pack	No. of packs sold	Qty.

*in case of bulk consumer give number and date of the order.

Signature

Verification

I &&&.. do hereby verify that what is stated above is true to the best of my knowledge and belief based on information derived from the records. I further declare that I am competent to and verify this statement in my capacity as&. (designation)

Signature&&&

Name&&&&.

Seal&&&&..

FORM XV
STOCK REGISTER OF TECHNICAL GRADE INSECTICIDE&.
[RULE 15]

DATE	Opening balance	Qty. imported	Quantity manufactured	Total quantity (2+3+4)	Qty. sold	Qty. utilised for formulation	Total quantity (6+7)	Closing balance

(quantity in metric ton)

&&&&&&&.

FORM XVI

STOCK REGISTER OF FORMULATED INSECTICIDE&&&&&&..

[RULE 15]

"triplicate'

FORM XVII
(Rule 24)

Report of insecticides analyst &&&&&.. sl. No&&&&&&&&&.

1. Name of the Insecticides inspector, from whom samples have been received.
2. Serial No. and date of Insecticides inspector's Memorandum.
3. Number of the sample.
4. Date of receipt.
5. Name of the insecticides purporting to be continued in the sample.
6. Condition of the seals on the package: state whether:-
7. (i) the sample was properly sealed and fastened (ii) the seal was intact and unbroken:
   
   (iii) the seal fixed on the container and the outer cover of the sample tallied with the specimen impression of the seal separately sent by the insecticides inspector, and
   
   (iv) the sample was in condition fit for analysis.
   
   
8. Date of the test or analysis.
9. Result of test or analysis with protocols of test applied.

Verification

I certify that I have analysed / caused to be analysed the aforementioned sample, and declare the result of analysis to be as above.

Signed this&& day of &&. 19&..

(signature with seal)

Insecticide Analyst

FORM XVIII
ORDER UNDER SECTION 21(1) (d) OF INSECTICIDES ACT, 1968 REQUIRING A PERSON NOT TO DISPOSE OF ANY STOCK IN HIS OSSESSION
(Rule 30)

whereas I reason to believe that the stock of &. In your possession detailed below, is being distributed, sold or used in contravention of the provisions of section&. Of insecticides act, 1968, or&. Of the insecticides rules, 1971.

I hereby require you under section 21(1)(d) of the said act to stop the districution, sales or use of the said stock for a period of &. Days from this date&.

Details of stock of insecticides/formulation..,

Date

1.

2.

Date

Insecticides Inspector

Seal

FORM XIX
FORM OF RECEIPT FOR THE SEIZED INSECTICIDES
[Rule 32]

Receipt for stock of insecticides seized under section 21((1)(d) of the Insecticides Act, 1968.

The stock of the insecticides detailed below has this day been seized by me under the provisions of section 21(1)(d) of the insecticides act, 1968 from the premises of&. Situated at.

Details of the insecticides seized are:

(a)

(b)

Date:

Insecticides Inspector

(Official Stamp)

FORM XX

INTIMATION TO PERSON / LICENSEE FROM WHOM SAMPLE IS TAKEN

[Rule 33]

To,

&&&&&&&&&&.

&&&&&&&&&&.

I have this day taken from the premises of &situated at &samples of the insecticides specified below for the purposes of test or analysis.

Date :

Insecticides inspector

Details of samples taken

Date:

Insecticides Inspector

FORM XXI

MEMORANDUM TO GOVERNMENT ANALYST

[Rule 34]

From

&&&&&&&&&..

To,

The Government Analyst

&&&&&&&&&&

The portion of samples / container described below is sent herewith for test or analysis under rule 34 of the Insecticides Rules, 1971. The portion of samples /container has been marked by me with the following mark:

Details of portion of sample or container with name of insecticide which it purports to contain.

Date :

Insecticides Inspector

(Seal)

FORM XXII

REGISTER OF PERSONS ENGAGED IN CONNECTION WITH INSECTICIDES AND THEIR PERIODICAL MEDICAL EXAMINATION FOR THE YEAR 19&&..

[Rule 37]

Serial No&&&.

Name&&&Age&&.

Father's/Husband's Name&&&&&Full address&&&

Sex&&&Identification mark&&

Date of appointment&&&&&..Occupation: (Please specify the nature of duty)

1. Past 2. Present

Past History

Illness	Poisoning	Allergy	Exposure to pesticides (Compound)	No, of Years/reason	Remarks, if any
1	2	3	4	5	6

Family History

Allergy	Psychological disorders	Haemorrhagic disorders
1	2	3

Personal History

Smoking	Alcohol	Other addiction
1	2	3

Observations

Medical Examination	Pre- employment examination	End of 1st quarter i.e. after 3 months	After 2nd quarter after 6 months	After 3rd quarter after 9 months	End of year	Remarks
1	2	3	4	5	6	7

1. General Examination

General body limit

Weight

Piles

Blood pressure

Respiration

Anaemia

Dadema

Jaundice

Skin condition

Temperature

Fatigability

Sweating

Sleep

Urination

II. Gastro Intestinal

Nausea

Vomiting

Appetite

Taste

Pain in abdomen

Bowel movement

Liver

Spleen

III. Cardio-respiratory

Nasal discharge

Wheeze

Cough

Expectoration

Tightness of chest

Dyspnoea

Palpitaion

Heart

Cyanosis

Tachycardia

IV. Neuro-muscular

Headache

Dizziness

Irritability

Pulse

Twitchings

Tremors

Convulsion

Paranesthesia

Hallucination

Unconsciousness

Deep reflexes

Superficial reflexes

Coordination

V. Eye

Pupil

Lachrymation

Double vision

Clumped vision

VI. Psychological

Temperament

Nervousness

VII. Kidney

Kidney condition

VIII Investigation

Blood hb%

Blood D.C.

*serum Cholinesterage

Serum Billirubin

Urine routine examination

Urine microscopic

x-ray of chest-

• serum cholinesterage level should be measured in monthly intervals in case of organophosphorus/ carbamatic group of insecticides. General remarks of the doctor in the light of the above examination;

advice given to;

1. 1. Doctor
   2. Employees:
   3. Employer / Manufacturer:
   4. Licensing officer at the time of inspection.

N.B. - in organochlorine group of insecticides the blood residue estimation should be done once a year.]