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Annual Medical Examination Form

The annual medical examination form records the periodic health check of an existing employee, comparing current results with the pre-employment baseline and the previous year. It focuses on changes linked to workplace exposure, such as hearing or lung function decline, and ends with the doctor's fitness review and advice.

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[Company Logo][Company Name]

ANNUAL / PERIODIC MEDICAL EXAMINATION FORM

Form No.:: [Reference Number]
Examination Year:: [Year]
Date:: [DD/MM/YYYY]
Examining Doctor:: Dr. [Doctor Name]

Section 1 – Employee and Exposure Details

Employee Name
Employee ID
Designation
Department / Section
Date of Joining
Main exposures this year (noise / dust / chemicals / heat / vibration / night shift / screen work)
Average working hours per week
PPE used regularly

Section 2 – Interval Health History

Since the last exam, have you had…	Yes / No	Details
New or worsening cough or breathlessness?		[Details]
Ringing in ears or difficulty hearing?		[Details]
Skin rashes or irritation?		[Details]
Back, neck or joint pain?		[Details]
Eye strain or headaches?		[Details]
Work injuries or sick leave over [Number] days?		[Details]

Section 3 – Year-on-Year Comparison

Parameter	Baseline (Joining)	Last Year	This Year	Change Noted
Weight / BMI	[Value]	[Value]	[Value]	[Remark]
Blood pressure	[Value]	[Value]	[Value]	[Remark]
Vision	[Value]	[Value]	[Value]	[Remark]
Audiometry	[Value]	[Value]	[Value]	[Remark]
Spirometry	[Value]	[Value]	[Value]	[Remark]

Section 4 – Additional Tests

Blood tests done and results
Exposure-specific tests and results
Other investigations

Section 5 – Fitness Review

Fit to continue in present job
Fit with restrictions: [Details] until [DD/MM/YYYY]
Refer to specialist: [Specialty]
Recommend temporary or permanent redeployment

Advice to employee
Recommendations to employer on workplace controls

Declaration

I confirm the history I provided is correct. I have been informed of my results. I consent to the fitness outcome and work recommendations being shared with HR and my supervisor; detailed reports will remain with the medical officer.

Employee
[Employee Name]
Date: [Date]

Examining Doctor
Dr. [Doctor Name]
Reg. No. [Registration Number]

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What this template includes

Employee's exposure history for the year (section, process, hours)
Interval health questionnaire on new symptoms
Year-on-year comparison table for key results
Exposure-specific tests tied to the role
Fitness review: continue, restrict, refer, redeploy
Advice to employee and recommendations to employer on controls

When to use it

Yearly health checks for factory workers in exposed processes
Periodic checks for drivers, operators and night-shift workers
Company-wide annual wellness check-ups for office staff
Health surveillance audits by clients or certifying bodies

How to customise this template

1Pull the previous year's values into the comparison table before the exam
2Use your role-wise test schedule from the occupational health policy
3Add lifestyle advice fields if running a wellness programme
4Schedule exams in batches by section to reduce production impact
5Send aggregate trends (not individual data) to the safety committee

HR tips

Track completion; missing employees often are the most exposed
Act on group trends, such as rising hearing loss in one area
Share each employee's own results with them
Keep records for the full period required by applicable rules

Periodic medical examinations for hazardous processes may be mandatory under the OSH Code, 2020 and state rules (with rules being notified); verify current test and frequency requirements with your medical officer.

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Frequently asked questions

Is an annual medical check-up mandatory for employees?+

For workers in certain hazardous processes it is required under applicable rules; for other employees it is a company benefit. The OSH Code also contemplates health check-ups for specified employees; check current rules.

What tests are part of an annual medical exam?+

Common tests include vitals, vision, blood tests and exposure-specific tests such as audiometry, spirometry or liver function for chemical exposure.

What happens if an employee's results worsen?+

The doctor may recommend restrictions, further tests or redeployment, and the employer should review controls in that work area.

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[Company Logo][Company Name]

PRE-EMPLOYMENT MEDICAL EXAMINATION FORM

Form No.:: [Reference Number]
Date:: [DD/MM/YYYY]
Clinic / Doctor:: [Clinic Name]

Part 1 – Candidate Details (to be filled by HR)

Candidate Name
Date of Birth
Gender
Designation Offered
Department
Work Location
Expected Date of Joining
Job exposures (noise / dust / chemicals / heat / height / driving / night shift / food handling)

Part 2 – Health Questionnaire (to be filled by Candidate)

Question	Yes / No	Details
Any ongoing medical condition relevant to the job?		[Details]
Any surgery or hospitalisation in the last [Number] years?		[Details]
Regular medicines currently taken?		[Details]
Any hearing, vision or breathing difficulty?		[Details]
Any back, joint or mobility issue?		[Details]
Any allergy (medicines, dust, chemicals)?		[Details]
Any workplace adjustment you would like us to consider?		[Details]

Part 3 – Clinical Examination (Doctor)

Form · Word

Pre-Employment Medical Form

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[Company Logo][Company Name]
COMPLAINT OF SEXUAL HARASSMENT AT THE WORKPLACE
To,
The Presiding Officer
Internal Committee, [Company Name]
[Company Address]
Email: [IC Email Address]

This form is confidential. You may attach additional sheets wherever space is insufficient.
Part A – Complainant Details
Full Name
Employee ID / Contractor / Visitor
Designation
Department
Work Location
Preferred Contact Number
Preferred Email
Best time and way to contact you
Part B – Respondent Details
Name of Respondent
Designation
Department / Organisation
Work Location
Relationship to you (manager, colleague, client, vendor, other)
Part C – Details of the Incident(s)
Form · Word
POSH Complaint Form
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Full Name
Employee ID / Contractor / Visitor
Designation
Department
Work Location
Preferred Contact Number
Preferred Email
Best time and way to contact you

Name of Respondent
Designation
Department / Organisation
Work Location
Relationship to you (manager, colleague, client, vendor, other)

[Company Logo][Company Name]

ANNUAL REPORT OF THE INTERNAL COMMITTEE

Reporting Period:: [DD/MM/YYYY] to [DD/MM/YYYY]
Date of Report:: [Date]
Submitted To:: The Employer and the District Officer, [District Name]

1. Establishment Details

Name of Organisation	[Company Name]
Address	[Company Address]
Nature of business
Total employees (Men / Women / Others)
Locations covered by this report

2. Composition of the Internal Committee

Name	Role	Gender	Appointed On	Remarks (changes during year)
[Member Name]	Presiding Officer	Female	[DD/MM/YYYY]	[Remarks]
[Member Name]	Member	[Gender]	[DD/MM/YYYY]	[Remarks]
[Member Name]	Member	[Gender]	[DD/MM/YYYY]	[Remarks]
[Member Name]	External Member	[Gender]	[DD/MM/YYYY]	[Remarks]

3. Complaints Summary

Report · Word

POSH Annual Report Format

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[Company Logo][Company Name]
POSH TRAINING FEEDBACK FORM
Session Date:
[DD/MM/YYYY]
Trainer:
[Trainer Name]
Batch / Location:
[Work Location]
Your feedback helps us improve. Writing your name is optional. Please do not use this form to report a complaint; contact the Internal Committee at [IC Email Address] or any committee member instead.
Section A – About You (optional)
Name (optional)
Department
Role level (Staff / Supervisor / Manager)
Employee or contract staff
Section B – Rate the Session (1 = Poor, 5 = Excellent)
Aspect 1 2 3 4 5
Content was clear and easy to understand
Examples were relevant to our workplace
Trainer handled questions well
Duration was appropriate
Language of delivery suited me
Form · Word
POSH Training Feedback Form
Download .docx
[Company Logo][Company Name]
WORKPLACE SAFETY INCIDENT REPORT
Incident No.:
[Reference Number]
Date of Report:
[Date]
Reported by:
[Employee Name], [Designation]
Part 1 – Incident Details
Date of incident [DD/MM/YYYY]
Time
Shift
Location / area / machine
Department
- Fire / smoke / explosion
- Electrical incident
- Chemical / gas / oil leak or spill
- Equipment, vehicle or machine failure
- Structural failure / falling object
- Injury to person (attach injury report)
- Property damage only
- Other: [Details]
Description: what happened, in sequence
Persons involved (name, ID, employee / contractor / visitor)
Witnesses (name, contact)
Part 2 – Immediate Action
Form · Word
Workplace Safety Incident Form
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[Company Logo][Company Name]
ACCIDENT REPORT FORM
Report No.:
[Reference Number]
Establishment:
[Company Name], [Work Location]
Date of Report:
[Date]
A. Injured Person
Name
Employee ID / Contractor Name
Designation
Department
Age
Gender
UAN
ESI IP Number (if covered)
Contact Number
Emergency Contact informed (name, time)
B. Accident Details
Date of accident [DD/MM/YYYY]
Time
Shift and hours worked before accident
Exact place
Activity being performed
Machine / tool / vehicle involved
How the accident happened
PPE being worn at the time
C. Injury Details
Form · Word
Accident Report Form
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[Company Logo][Company Name]
FIRST AID INCIDENT FORM
Form No.:
[Reference Number]
Date:
[DD/MM/YYYY]
Time:
[Time]
Location:
[Work Location]
Person Treated
Name
Employee ID / Visitor / Contractor
Department / Company
Age
Contact Number
Complaint or Injury
- Cut / abrasion
- Burn
- Sprain / strain
- Eye irritation / foreign body
- Fainting / dizziness
- Headache / fever
- Allergic reaction / insect bite
- Other: [Details]
Brief description of what happened
Work-related? (Yes / No)
Body part affected
Form · Word
First Aid Incident Form
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[Company Logo][Company Name]
MEDICAL FITNESS CERTIFICATE
Certificate No.:
[Reference Number]
Date of Examination:
[DD/MM/YYYY]
Valid Until:
[DD/MM/YYYY]
To,
The HR Department
[Company Name]
[Company Address]
Details of Person Examined
Name [Candidate Name]
Age / Date of Birth
Gender
Identity document verified (type and last 4 digits)
Photograph attested by doctor (affix here)
Job for Which Fitness Is Certified
Designation [Designation]
Department [Department]
Job demands stated by employer (lifting, standing, night shift, driving, height, chemicals, food handling)
Certificate · Word
Medical Fitness Certificate
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Name (optional)
Department
Role level (Staff / Supervisor / Manager)
Employee or contract staff

Aspect	1	2	3	4	5
Content was clear and easy to understand
Examples were relevant to our workplace
Trainer handled questions well
Duration was appropriate
Language of delivery suited me

Date of incident [DD/MM/YYYY]
Time
Shift
Location / area / machine
Department

Description: what happened, in sequence
Persons involved (name, ID, employee / contractor / visitor)
Witnesses (name, contact)

Name
Employee ID / Contractor Name
Designation
Department
Age
Gender
UAN
ESI IP Number (if covered)
Contact Number
Emergency Contact informed (name, time)

Date of accident [DD/MM/YYYY]
Time
Shift and hours worked before accident
Exact place
Activity being performed
Machine / tool / vehicle involved
How the accident happened
PPE being worn at the time

Name
Employee ID / Visitor / Contractor
Department / Company
Age
Contact Number

Brief description of what happened
Work-related? (Yes / No)
Body part affected

Name	[Candidate Name]
Age / Date of Birth
Gender
Identity document verified (type and last 4 digits)
Photograph attested by doctor (affix here)

Designation	[Designation]
Department	[Department]
Job demands stated by employer (lifting, standing, night shift, driving, height, chemicals, food handling)

Annual Medical Examination Form

Preview of the form

Section 1 – Employee and Exposure Details

Section 2 – Interval Health History

Section 3 – Year-on-Year Comparison

Section 4 – Additional Tests

Section 5 – Fitness Review

Declaration

What this template includes

When to use it

How to customise this template

HR tips

Hire top talent from BetterJobs

Frequently asked questions

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