FORM No. 12

(See Subsidiary Rules 89—90)

Medical certificates for leave


Statement of the case of...............................

The statement of the case must always be furnished.

Name (to be filled in by the applicant in the presence of the Chief Medical Officer or the authorised medical attendant).

The signature of the applicant should be taken by the certifying officer before he proceeds to fill in the form. (Vide note below and under Subsidiary Rule 89).

Appointment held


Total service

Previous periods of leave of

absence on medical certificate.




I...........................................Chief Medical Officer/Authorised Medical Attendant at.............................or of.........................after careful and personal examination of the case hereby certify that Shri/Shrimati/ in a bad state of health and I solemnly and sincerely declare that, according to the best of my judgement, a period of absence from duty is essentially necessary for the recovery of his/her health and recommend that he/she may be granted leave for............ with effect from.............................

*In my opinion it is/ it is not necessary for the officer to appear before a medical board.

* This sentence should either be modified by scoring out the irrelevant words or altogether scored out according as the period of leave recommended is up to three months or exceeds that period.

Chief Medical Officer/Authorised Medical Attendant.


NOTE 1—This form should be adhered to as closely as possible and should be filled in after the signature of the government servant applying for leave has been taken. This certifying officer is not at liberty to certify that the applicant requires a change from or to a particular locality or that he/she is not fit to proceed to a particular locality. Such certificate should only be given at the explicit request of the sanctioning authority to whom it is open to decide when an application on such grounds has been made to him, whether the government servant should go before a medical board to decide the question of his/her fitness for service.

NOTE 2—The medical certificate and history of the case as also the certificate prescribed in rule 91 or 94 (b), as the case may be, should be prepared in duplicate. One copy of which the government servant proceeding on leave should take with him/her for presentation to the medical board or officer who examines him/her for fitness before his/her return to duty.

Medical Committee’s Report

The report of a medical committee must always be furnished unless the certificates on the reverse are utilized.

(Subsidiary Rules 91 and 93.)

"We do hereby certify that according to the best of our professional judgement, after careful personal examination of the case, we consider the health of Shri/Shrimati/ be such as to render leave of absence for a period of...................absolutely necessary for his/her recovery."


————————— Members.




NOTE—In cases in which the leave recommended is for more than three months or leave for three months or less is extended beyond three months, the Medical Board shall state at the time of granting the certificate whether the government servant should or need not appear before another Medical Board for obtaining the certificate of fitness for return to duty.

Certificate of Civil Surgeon

This certificates must always be furnished when the government servant concerned cannot appear before a medical committee.

I hereby certify that the state of health of —————is such as to make it highly inconvenient for him/her to proceed to————for the purpose of appearing before a medical committee. Dated Civil Surgeon The Medical Officer’s certificate

This certificate should be signed by two medical officers, either commissioned or in charge of civil stations. When this is signed by only one medical officer, it should be countersigned by the commissioner of the division or the district officer or in the case of a government servant of the Judicial department by the District and Sessions Judge. When two medical officers do not sign, reasons must be given why two officers have not signed.

I/We do hereby certify that, according to the best of our professional judgement, after careful personal examination of the case, I/We consider the health of———to be such as to render leave of absence for a period of—————absolutely necessary for his/her recovery.




or District Magistrate


or District and Sessions Judge.



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