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Maternity Forms

This document contains 4 forms related to maternity benefits under the Maternity Benefit Act of 1961. Form 1 is a notice from a woman employee to her employer informing them that she expects to be confined within 6 weeks or has given birth on a given date. Form 2 is a medical certificate from a registered medical practitioner certifying the expected delivery date or that delivery or miscarriage has occurred. Form 3 is a medical certificate from a registered midwife certifying that delivery or miscarriage has occurred. Notes are provided defining "child" and "miscarriage" under the Act.

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Lalita Thakur
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2K views3 pages

Maternity Forms

This document contains 4 forms related to maternity benefits under the Maternity Benefit Act of 1961. Form 1 is a notice from a woman employee to her employer informing them that she expects to be confined within 6 weeks or has given birth on a given date. Form 2 is a medical certificate from a registered medical practitioner certifying the expected delivery date or that delivery or miscarriage has occurred. Form 3 is a medical certificate from a registered midwife certifying that delivery or miscarriage has occurred. Notes are provided defining "child" and "miscarriage" under the Act.

Uploaded by

Lalita Thakur
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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FORM 1

[See rule 3]

Notice under section 6 of the maternity Benefit Act of 1961

To,

………………………………………………………………………………………………………………
(Name of employer)

I,………………………………… (Name of woman)*wife/*daughter of ……………………………employed

as …………………….. at ……………………………………hereby give you notice that I* expect to be confined

within six weeks from the date of this notice and shall be absent from work from ……………………….. /

*have given birth to a child on ……………………………….. .

The maternity benefit and any other amount to which I am entitled under the provisions of the Maternity Benefit

Act, 1961, may be paid to ……………………………………………………………*Me/*Shri/Shrimathi/Kumari.

I shall not work in any establishment during the period for which I receive maternity benefit.

Date………………………………………………….

Signature of an attestor in case the woman is Signature or Thumb impression


Not able to sign, and affixes thumb impression of woman

* To be struck off when not applicable


FORM 2
[See rule 5 (1)]

This is to certify that I examined…………………………………………………………………*wife/* daughter

of ……………………. A woman employed in ………………………………on ……………………………and.

*found that she is pregnant and is expected to be delivered of a child within ………………………………………

(mention months and days) from the above-mentioned date / * found that she is delivered of a child on ………….

…………………………………… /* found that she had miscarriage on …………………………………………./

found that she is suffering from …………………………………….. ………….……..an illness arising out of her

*pregnancy / *delivery / *premature birth of a child / *miscarriage.

Date……………………….. Signature, qualifications and designation


if any, of registered medical practitioner.

Note. - The expressions “child” and “miscarriage” are defined in the Act as follows:-

(1) “ Child” includes a still-born child;

(2) “Miscarriage” means expulsion of the contents of a pregnant uterus at any period prior to or during
the twenty-sixth week of pregnancy but shall not include any miscarriage, causing of which is punishable under
the Indian Penal Code (45 of 1880).

* To be struck off when not applicable


FORM 3
[See rule 8(1)]

This is to certify that I examined ………………………………*wife/*daughter of……………….........................

a woman employed in ………………………………………………...and found that * she has been delivered of a

child on ………………………………………./ *she had miscarriage on ……………………………………… .

Date……………………………….. Signature of a registered midwife.

Note. - The expressions “child” and “miscarriage” are defined in the Act as follows:-

(1) “ Child” includes a still-born child;

(2) “Miscarriage” means expulsion of the contents of a pregnant uterus at any period prior to or during
the twenty-sixth week of pregnancy but shall not include any miscarriage, causing of which is punishable under
the Indian Penal Code (45 of 1880).

* To be struck off when not applicable

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