Form 5 — CCS

We, the members of Medical Board I, ...................................................... Civil Surgeon/Staff Surgeon. Authorized Medical Attendant of…. Registered Medical Practitioner do hereby certify that we / I have carefully examined Shri / Shrimati I Kumari ……………………..whose signature is given above, and find that he/she recovered from his I her illness and is now fit to resume duties in Government service. We / I also certify that before arriving at this decision, we If have examined the original medical certificate

(s) and statement

(s) of the case (or certified copies thereof) on which leave was granted or extended and have taken these into consideration in arriving at our / my decision.

Members of the Medical Board (1)………………………… (2)………………………… (3)………………………… Civil Surgeon / Staff Surgeon Authorized Medical Attendant Registered Medical Practitioner

NOTE.- The original medical certificate

(s) and statement

(s) of the case on which the leave was originally granted or extended shall be produced before the authority required to issue the above certificate. For this purpose, the original certificate

(s) and statement

(s) of the case should be prepared in duplicate, one copy being retained by the Government servant concerned.

FORM 5 [See Rule 24 (3)] MEDICAL CERTIFICATE OF FITNESS TO RETURN TO DUTY Signature of the Government servant ………………………………