Periodical medical examination notice form prescribed for mine managers when a worker misses examination without reasonable cause. Second notice of periodical medical examination is prescribed for use by a mine manager where a person required to undergo medical examination has failed, without reasonable cause, to attend after an earlier notice. The form requires the person to be again notified to appear before the examining authority on the specified date and time, and the notice is to be forwarded by the mine manager to the examining authority. The prescribed form applies to all mines under sub-rule (4) of Rule 111.