FORM B: Medical Certificate

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[Rule 4(1)]

This is to certify that I examined ____________ wife/daughter of ____________ a woman employee in __________ (name of ³[mine or circus]) on _________ (date) and found/ cannot discover that she is pregnant and is expected to be delivered of a child within (month and/days) from the above mentioned date/has under gone miscarriage/ ³[medical termination of pregnancy or tubectomy operation]/ has been delivered of a child on _______ (date) or is suffering from _______ (date) from illness arising out of pregnancy/delivery/premature birth of a child or miscarriage/³[medical termination of pregnancy of tubectomy operation].

Signature, qualifications and designation of Medical Officer/Medical Practitioner

Date _________

Definitions of "child" and "miscarriage" as in the Maternity Benefit Act, 1961-

1. "Child" includes a still-born child

2. "Miscarriage" means expulsion of the contents of a pregnant uterus at any period prior to or during the twenty-sixth week of pregnancy but does not include any miscarriage, the causing of which is punishable under the Indian Penal Code.

 

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