FORM I
(G.O. 272(2))
REPORT OF MEDICAL BOARD
MEDICAL REPORT ON AN OFFICER IN PUBLIC SERVICE

Name of Officer Examined: ................................................................................................................................
I/C No.:....................................................................... Sex:..................................................................................
Date of Birth: .......................................................................................................................................................
Department:..........................................................................................................................................................
Appointment:.......................................................................................................................................................
Hospital:................................................................................................................................................................
Date:......................................................................................................................................................................

The Medical Board has carried out an examination on the above named officer, at the request of the State Secretary and the following is the report of the said examination:

Grounds for carrying out examination

1.	The officer is required to have his fitness examined because:
	*he has exhausted his normal sick leave entitlement
	*a medical officer has so recommended
	*he has been absent on sick leave for a total of 45 days or more in each of the three successive years
	his physical/mental fitness is in doubt
	*the extension of sick leave for him has been recommended on grounds of injury suffered in the course of official duty
	he has been recommended leave on half-pay/leave without pay for suffering from tuberculosis/leprosy/cancer/such other sickness ................................................................................ (state nature of sickness)

Date and Particulars of Examination

2.	(a)	*The Board has examined the officer on ..............................................................................................
	(b)	The Board has placed the officer under medical care/medical treatment from ................................................................................ to ................................................................................
	(c)	*The medical history of the officer, as could be observed by the Medical Board, is as follows (if long, attach appendix): ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... .......................................................................................................................................................................

Confirmation of Board

3.	The Board certifies that the officer is-
	*in good health
	*suffering from.....................................................................................................................................................

Opinion of the Board

4.	The Board is of the opinion that the illness or injury of the officer-
	*will/will not be permanent
	*will/will not make him unfit to perform the duties of ................................................................................
	*will/will not make him unfit to perform any other duties.

Recommendation of Medical Board

The Medical Board recommends that he be considered as-

(a)	*unfit permanently/unfit temporarily/fit to resume duties
(b)	*as fit to continue duties, but on health grounds he should be granted leave as early as possible for ................................ weeks.

Additional Recommendations/Views of Medical Board

(State here any additional recommendations or views of the Medical Board)
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(1)	Signature of member of Medical Board ....................................................................................
	Full name:.......................................................................................................................................
	Appointment:................................................................................................................................
	Date:...............................................................................................................................................
(2)	Signature of member of Medical Board
	Full name:.......................................................................................................................................
	Appointment:................................................................................................................................
	Date:................................................................................................................................................

*Delete whichever is inapplicable