Free form template · Word

Employee Health Declaration

The employee health declaration is a short self-declaration in which an employee confirms they are fit to work and discloses only information relevant to safety, such as infectious symptoms, medicines causing drowsiness for machine operators or drivers, and emergency medical details like allergies or blood group.

Editable Word (.docx)
Made for India
8 fill-in fields highlighted
Free, no sign-up

Download Word (.docx) — free

Preview of the form

[Highlighted] = fill in

[Company Logo][Company Name]

EMPLOYEE HEALTH SELF-DECLARATION

Company:: [Company Name]
Date:: [DD/MM/YYYY]
Purpose:: [Shift fitness / Outbreak screening / Travel / Food handling / Emergency info]

Why we ask: This declaration helps us keep you and your colleagues safe. The information will be seen only by [HR Name / Medical Officer], used only for the purpose above, and deleted after [Number] months.

Employee Details

Employee Name
Employee ID
Designation
Department
Work Location
Mobile Number

1. Fitness to Work

I am currently fit to perform my normal duties
I have a temporary condition that may affect my work (HR / medical officer will contact me)

2. Infectious Symptoms (in the last [Number] days)

Symptom	Yes	No
Fever
Persistent cough or sore throat
Vomiting or diarrhoea
Skin infection or rash (food handlers)
Close contact with a person with a notifiable infectious illness

3. Safety-Critical Roles Only (drivers, operators, work at height)

Are you taking any medicine that causes drowsiness or affects alertness? (Yes / No)
If yes, has your doctor cleared you for this work? (Yes / No)

4. Emergency Medical Information (voluntary)

Blood group
Known allergies (medicines, food, insects)
Condition first-aiders should know about in an emergency
Emergency contact name and number

Declaration

I declare that the information given is true to the best of my knowledge. I will inform [HR Name] if my health changes in a way that affects safety at work. I consent to this information being used only for the purpose stated above.

Employee
[Employee Name]
Date: [Date]

Received by
[HR Name]
Date: [Date]

Download Word (.docx) — free

What this template includes

Purpose statement explaining why information is collected
Fitness-to-work confirmation
Infectious symptom check relevant to the period
Safety-critical medicine disclosure for operators and drivers
Voluntary emergency medical info (blood group, allergies)
Data privacy and limited-use assurance

When to use it

During outbreaks of infectious illness when symptom screening is needed
For drivers and machine operators at the start of a contract or shift roster
Before off-site travel, treks or offsite events
For kitchen and food-handling staff
To collect voluntary emergency medical information

How to customise this template

1Keep only the sections relevant to your purpose
2Update the symptom list based on current public health advice
3Decide who sees the form (medical officer or HR only)
4Set how long declarations are retained before deletion
5Offer a digital version through the HRMS

HR tips

Collect the minimum information needed; avoid general medical history
Make emergency info voluntary and say so
Do not penalise employees who declare symptoms; send them home on leave as per policy
Store forms away from appraisal and personnel files

Health data is sensitive personal data; collect only what is necessary, with consent and purpose stated, and align with the Digital Personal Data Protection Act, 2023 and its rules as applicable, plus any public health directions in force.

For HR & hiring managers

Experienced and fresher candidates across India — blue, grey and white collar. Post a job in 5 minutes and start receiving applications.

Post a job free See plans

Post in 5 minutesDescribe the role in one line — we write the job description.
Verified applicantsEvery applicant has a verified mobile number.
Resume databaseSearch experienced candidates by skill, city and experience.

Frequently asked questions

Can an employer ask employees to declare health conditions?+

An employer can ask for information that is relevant to safety or the job, with a clear purpose and consent. Avoid asking for unrelated medical history.

Is the health declaration confidential?+

It should be. Limit access to HR or the medical officer and use it only for the stated purpose.

What if an employee declares symptoms?+

Follow your policy, typically advising them to stay home, seek medical advice, and return with clearance. Leave should be handled fairly.

All 50 posh, workplace safety & compliance →

[Company Logo][Company Name]
WRITTEN STATEMENT TO THE INTERNAL COMMITTEE
Complaint Ref. No.:
[Reference Number]
Date of Submission:
[DD/MM/YYYY]
Classification:
Confidential
Instructions: Write in your own words. Stick to facts with dates and places. This statement will be shared with the other party for response as part of a fair inquiry. Attach extra sheets if needed.
Section 1 – Details of the Person Making the Statement
Name
Employee ID
Designation
Department
Reporting Manager
Work Location
Role in the case (Complainant / Respondent)
Section 2 – Type of Statement
- Reply to complaint (respondent)
- Additional statement (complainant)
- Rejoinder to the other party's statement
- Response to witness statement(s)
- Final written submission
Form · Word
POSH Employee Statement
Download .docx
[Company Logo][Company Name]
CONFIDENTIALITY DECLARATION – POSH PROCEEDINGS
Company:
[Company Name]
Complaint Ref. No. (if specific):
[Reference Number]
Date:
[Date]
Signatory Details
Name
Employee ID / Organisation
Designation
Contact Number
- Presiding Officer / Member of Internal Committee
- External Member
- Complainant
- Respondent
- Witness
- HR / Administrative support to the committee
- Interpreter / Other (specify)
Undertaking
I, [Name], understand that I have been or may be given access to information relating to a complaint of sexual harassment under the Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013 and the POSH policy of [Company Name]. In consideration of this access, I undertake as follows:
Form · Word
POSH Confidentiality Declaration
Download .docx
[Company Logo][Company Name]
OCCUPATIONAL HEALTH POLICY
Policy No.:
[Reference Number]
Effective Date:
[DD/MM/YYYY]
Owner:
[HR Head / Factory Medical Officer]
1. Purpose
This policy sets out how [Company Name] protects and promotes the health of its workforce by identifying work-related health risks, monitoring the health of exposed employees, and supporting employees to work safely and return to work after illness.
2. Scope
It applies to all employees and, where specified, to contract workers engaged at [Work Location] and other company premises.
3. Definitions
Policy · Word
Occupational Health Policy
Download .docx
[Company Logo][Company Name]
HEALTH & SAFETY CHECKLIST
Premises:
[Work Location]
Checked by:
[Employee Name], [Designation]
Date:
[DD/MM/YYYY]
Period:
[Month / Week]
Fire Safety
- Fire extinguishers in place, pressure gauge in green, refill date valid
- Emergency exits unlocked, unobstructed and signed
- Fire alarm / smoke detectors tested this month
- Evacuation plan displayed on each floor
- No storage of combustible material near electrical panels
Electrical Safety
- No loose wires, damaged plugs or exposed cables
- No overloaded multi-plug sockets or daisy-chained extensions
- Electrical panels closed, labelled, with clear access
- UPS / battery room ventilated and dry
First Aid
Checklist · Word
Health & Safety Checklist
Download .docx

Name
Employee ID
Designation
Department
Reporting Manager
Work Location
Role in the case (Complainant / Respondent)

Name
Employee ID / Organisation
Designation
Contact Number

[Company Logo][Company Name]

EMPLOYEE INJURY REPORT

Report No.:: [Reference Number]
Date Submitted:: [Date]

1. Employee Details

Employee Name
Employee ID
Designation
Department
Reporting Manager
Work Location / Work from Home
ESI IP Number (if applicable)

2. Your Account of the Injury

Date and time of injury or when symptoms started
Where were you and what task were you doing?
Describe how it happened in your own words
Was it a sudden event or gradual (over days or weeks)?
Body part affected and symptoms
Did anyone see it happen? Names

3. Reporting

Report · Word

Employee Injury Report

Download .docx

[Company Logo][Company Name]

CONTRACTOR SAFETY DECLARATION AND UNDERTAKING

Ref. No.:: [Reference Number]
Date:: [Date]
Work Order / PO No.:: [Reference Number]

Contractor Details

Contractor / Firm Name
Address
GSTIN
Contract labour licence no. (if applicable)
ESI code / PF code
Contact person and mobile
Contractor safety supervisor name

Scope of Work

Description of work
Location within premises
Start date and expected end date
Maximum number of workers
Hazardous activities involved (hot work / height / electrical / confined space / chemicals / lifting)

Undertaking

Agreement · Word

Contractor Safety Declaration

Download .docx

Form · Word
Visitor Safety Declaration
Download .docx

Name
Organisation
Mobile Number
ID type and last 4 digits
Purpose of visit
Areas to be visited
Vehicle number (if any)

Host Employee Name
Department
Extension / Mobile

[Company Logo][Company Name]

HEALTH & SAFETY AUDIT CHECKLIST

Site:: [Company Name], [Work Location]
Audit Date(s):: [DD/MM/YYYY]
Lead Auditor:: [Auditor Name]
Audit Team:: [Names]
Scoring:: 0 = Not in place, 1 = Partly in place, 2 = Fully in place with evidence

A. Leadership and Policy

Question	Score (0-2)	Evidence Seen
Signed safety policy reviewed in the last 12 months?		[Evidence]
Safety objectives and targets set and tracked?		[Evidence]
Management safety walks recorded?		[Evidence]

B. Hazard Identification and Risk Control

Question	Score (0-2)	Evidence Seen
Risk assessments exist for all major activities?		[Evidence]
Permit-to-work system used for high-risk work?		[Evidence]
Change management reviews safety before process changes?		[Evidence]

C. Training and Competence

Checklist · Word

Health & Safety Audit Checklist

Download .docx

Employee Health Declaration

Preview of the form

Employee Details

1. Fitness to Work

2. Infectious Symptoms (in the last [Number] days)

3. Safety-Critical Roles Only (drivers, operators, work at height)

4. Emergency Medical Information (voluntary)

Declaration

What this template includes

When to use it

How to customise this template

HR tips

Hire top talent from BetterJobs

Frequently asked questions

Related HR templates