Form 4 — CCS

FORM 4 [See Rule 19] MEDICAL CERTIFICATE FOR LEAVE OR EXTENSION OF LEAVE OR COMMUTATION OF LEAVE Signature of the Government servant………………………………….. I, ................................ after careful personal examination of the case hereby certify that Shri / Shrimati / Kumari..........................whose signature is given above, is suffering from ………………and I consider that a period of absence from duty of ……………with effect from …………….is absolutely necessary for the restoration of his / her health.

Authorized Medical Attendant ……………Hospital / Dispensary or other Registered Medical Practitioner NOTE 1- The nature and probable duration of the illness should be specified.

NOTE 2- This Form should be adhered to as closely as possible and should be filled in after the signature of the Government servant has been taken. The certifying officer is not at liberty to certify that the Government servant requires a change from or to a particular locality, or that he is not fit to proceed to a particular locality. Such certificates should only be given at the explicit desire of the administrative authority concerned, to whom it is open to decide, when an application on such grounds has been made to him, whether the applicant should go before a Civil Surgeon or Staff Surgeon to decide the question of his/her fitness for service.

NOTE 3.- Should a second medical opinion be required, the authority competent to grant leave should arrange for the second medical examination to be made at the earliest possible date by a Medical Officer not below the rank of a Civil Surgeon or Staff Surgeon, who shall express an opinion both a regards the facts of illness and as regards the necessity for the amount of leave recommended and for this purpose he may either require the Government servant to appear before himself or before a Medical Officer nominated by himself.

NOTE 4.- No recommendation contained in this certificate shall be evidence of a claim to any leave not admissible to the Government servant.