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Medical Certificate for Govt. Servants
FORM NO. 3 (SEE RULE 18)
RECOMMONDED LEAVE OR EXTENSION OF LEAVE OR COMMUTATION OF LEAVE
Signature of the Govt. Servant ………………………………………
I …………………………………….. after careful personal examination of the case hereby certify that
Shri/Smt./Kumari …………………………………………………………………whose signature is given above,
is suffering from ……………………………………………………………………………
and I consider that is absolutely necessary for the restoration of his/her health.
Date …………………
Authorised Medical Attendant
…………..Hospital/Dispensary
Or Reg. Medical Practitioner
FORM NO. 4 [SEE RULE 23(3)]
Medical Certificate for Govt. Servants
RECOMMONDED LEAVE OR EXTENSION OF LEAVE OR COMMUTATION OF LEAVE
Signature of the Govt. Servant …………………………
I …………………………………………………………………..……….. Civil surgeon/Staff Surgeon
Authorised Medical Attendant
………………………………………………………
Registered Medical Practitioner
Do hereby certify that I have carefully examined Shri/SMt.Kumari ………………………...……whose signature
is given above and find that he/she has recovered from his her illness and is now fit to resume duties in Govt.
service. I also certify that before arriving at this decision, I have examined the original medical certificate and
statements of the case (or certified copies thereof) on which leave was granted or extended and have taken there
into consideration in arriving at my decision.
Date …………………
Civil surgeon/ Sttaff surgeon
Authoresed Medical attendant
Registered Medical Practitioner
