Free form template · Word

Medical Certificate Submission Form

A medical certificate submission form is the cover sheet an employee attaches when handing a doctor's sickness or fitness certificate to HR. It records the certificate details, links it to the leave application and lets HR verify and file it confidentially.

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

Download Word (.docx) — free

Preview of the form

[Highlighted] = fill in

[Company Logo][Company Name]

MEDICAL CERTIFICATE SUBMISSION FORM

Company:: [Company Name]
Leave Application Ref.:: [Reference Number]
Date of Submission:: [Date]

A. Employee Details

Employee Name	[Employee Name]
Employee ID	[Employee ID]
Department	[Department]
Reporting Manager	[Reporting Manager]

B. Certificate Details

Type	[ ] Sickness certificate [ ] Fitness certificate [ ] Both
Issued by (Doctor Name)
Medical registration number
Hospital / clinic and city
ESI certificate number (if applicable)
Date of issue	[DD/MM/YYYY]
Period of rest advised	[DD/MM/YYYY] to [DD/MM/YYYY]
Fit to resume duty from	[DD/MM/YYYY]
Restrictions on work, if any (e.g. no lifting, no night shift) and duration

C. Documents Attached

Original / scanned medical certificate
Discharge summary (if hospitalised)
Prescriptions or test reports only if specifically requested by HR

Declaration: I confirm that the attached certificate(s) are genuine and relate to my own illness / treatment. I consent to HR verifying the certificate with the issuing doctor or hospital if necessary. I understand that these documents will be kept confidential and used only for leave and workplace adjustment purposes.

Employee
[Employee Name]
Date: [Date]

D. For HR Use

Certificate received on	[DD/MM/YYYY]
Verified	[ ] Yes [ ] Not required [ ] Clarification sought
Leave regularised as	[Leave Type] for [Number] days
Work restrictions communicated to manager	[ ] Yes [ ] Not applicable
Filed in confidential medical file on	[DD/MM/YYYY]

HR
[HR Name]
Date: [Date]

Download Word (.docx) — free

What this template includes

Link to the leave application reference
Certificate type: sickness, fitness or both
Doctor and registration details for verification
Period of rest advised and any work restrictions
Confidential handling statement
HR verification and filing record

When to use it

Sick leave exceeds the number of days after which the policy requires a certificate
Submitting a fitness certificate before rejoining after illness or surgery
Certificates issued by ESI dispensaries or hospitals for ESI-covered employees
Recording receipt of certificates sent by email or courier

How to customise this template

1State your policy threshold for certificates as [Number] days
2Add a field for ESI certificate number for ESI-covered staff
3Include a restrictions section for factory or field roles
4Define who in HR has access to medical files

HR tips

Store medical documents separately from the general personnel file
Ask only for what is needed: period of rest and fitness, not full diagnosis
Respect work restrictions in the fitness certificate when assigning duties
Verify doubtful certificates discreetly and fairly

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

What should a medical certificate for office leave contain?+

Typically the patient's name, period of rest advised, a general statement of illness, doctor's name, registration number, signature, clinic stamp and date.

Do I need a fitness certificate to rejoin work?+

Many companies ask for one after long medical leave, surgery or infectious illness, and especially for safety-sensitive roles. Check your leave policy.

Can HR ask for my diagnosis?+

HR generally needs only confirmation of illness and period of rest. Detailed diagnosis should be shared only where necessary, such as for workplace adjustments, and kept confidential.

All 50 leave management →

[Company Logo][Company Name]

LEAVE APPLICATION FORM

Company:: [Company Name]
Form No.:: [Reference Number]
Date of Application:: [Date]

Part A – Employee Details

Employee Name
Employee ID
Designation
Department
Reporting Manager
Work Location
Mobile Number

Part B – Leave Details

Type of Leave	[ ] Casual [ ] Sick [ ] Earned/Privilege [ ] Compensatory Off [ ] Leave Without Pay [ ] Other: [Specify]
From Date (DD/MM/YYYY)
To Date (DD/MM/YYYY)
Number of Working Days
Half Day	[ ] First Half [ ] Second Half [ ] Not Applicable
Reason for Leave
Address and Phone Number During Leave

Part C – Work Handover

Form · Word

Leave Application Form

Download .docx

[Company Logo][Company Name]
LEAVE REQUEST FORM
Company:
[Company Name]
Request Date:
[Date]
Employee
Name [Employee Name]
Employee ID [Employee ID]
Team / Department [Department]
Shift (if applicable)
Manager [Reporting Manager]
Leave Requested
Leave Code From (DD/MM/YYYY) To (DD/MM/YYYY) Total Days
[CL/SL/EL/CO/LWP] [DD/MM/YYYY] [DD/MM/YYYY] [Number]
[Leave Code] [DD/MM/YYYY] [DD/MM/YYYY] [Number]
Purpose (brief)
Reachable on (phone / email)
Form · Word
Leave Request Form
Download .docx
Form · Word
Leave Approval Form
Download .docx

Name	[Employee Name]
Employee ID	[Employee ID]
Team / Department	[Department]
Shift (if applicable)
Manager	[Reporting Manager]

Leave Code	From (DD/MM/YYYY)	To (DD/MM/YYYY)	Total Days
[CL/SL/EL/CO/LWP]	[DD/MM/YYYY]	[DD/MM/YYYY]	[Number]
[Leave Code]	[DD/MM/YYYY]	[DD/MM/YYYY]	[Number]

Purpose (brief)
Reachable on (phone / email)

Leave Type Applied
Period Applied: From [DD/MM/YYYY] To [DD/MM/YYYY]
Days Applied

[Company Logo][Company Name]

MEDICAL LEAVE APPLICATION FORM

Company:: [Company Name]
Form No.:: [Reference Number]
Date:: [Date]

1. Employee Details

Employee Name	[Employee Name]
Employee ID	[Employee ID]
Designation / Department	[Designation] / [Department]
Reporting Manager	[Reporting Manager]

2. Reason for Medical Leave

[ ] Hospitalisation [ ] Planned surgery [ ] Prolonged illness [ ] Accident (outside work) [ ] Injury at work – Accident Report No. [Reference Number]
Brief description (no detailed diagnosis needed)
Treating doctor / hospital name and city
Date of admission / start of illness	[DD/MM/YYYY]

3. Leave Period and Leave Heads

Form · Word

Medical Leave Application

Download .docx

[Company Logo][Company Name]
RETURN FROM LEAVE / RESUMPTION OF DUTY FORM
Company:
[Company Name]
Date:
[Date]
1. Employee Details
Employee Name [Employee Name]
Employee ID [Employee ID]
Designation / Department [Designation] / [Department]
Shift (if applicable)
2. Leave Details
Particulars Sanctioned Actual
Leave type [Leave Type] [Leave Type]
From [DD/MM/YYYY] [DD/MM/YYYY]
To [DD/MM/YYYY] [DD/MM/YYYY]
Days [Number] [Number]
Reported for duty on [DD/MM/YYYY] at [HH:MM]
Reason for any difference between sanctioned and actual leave
Form · Word
Return From Leave Form
Download .docx

Particulars	Sanctioned	Actual
Leave type	[Leave Type]	[Leave Type]
From	[DD/MM/YYYY]	[DD/MM/YYYY]
To	[DD/MM/YYYY]	[DD/MM/YYYY]
Days	[Number]	[Number]

Reported for duty on	[DD/MM/YYYY] at [HH:MM]
Reason for any difference between sanctioned and actual leave

[Company Logo][Company Name]

LEAVE CARRY FORWARD FORM – LEAVE YEAR [YYYY]

Company:: [Company Name]
Form No.:: [Reference Number]
Date:: [Date]

A. Employee Details

Employee Name	[Employee Name]
Employee ID	[Employee ID]
Department	[Department]

B. Year-End Position

Leave Head	Closing Balance	Carry-Forward Cap	Eligible to Carry Forward	Excess Days
Earned / Privilege Leave	[Number]	[Number]	[Number]	[Number]
Sick Leave	[Number]	[Number]	[Number]	[Number]
Casual Leave	[Number]	Lapses	0	[Number]

C. Employee Choice for Excess Earned Leave

Form · Word

Leave Carry Forward Form

Download .docx

[Company Logo][Company Name]
LEAVE / ATTENDANCE ADJUSTMENT FORM
Company:
[Company Name]
Form No.:
[Reference Number]
Date:
[Date]
1. Employee Details
Employee Name [Employee Name]
Employee ID [Employee ID]
Department [Department]
Reporting Manager [Reporting Manager]
2. Type of Adjustment
[ ] Change of leave type [ ] Reversal of wrong debit [ ] LWP to paid leave [ ] Absent to present (missed punch / official duty / travel) [ ] Half day to full day or vice versa [ ] Other [Specify]
3. Entries to be Corrected
Form · Word
Leave Adjustment Form
Download .docx
[Company Logo][Company Name]
LEAVE APPLICATION – NOT APPROVED
Ref. No.:
[Reference Number]
Date:
[Date]
To,
[Employee Name]
[Designation], [Department]
Employee ID: [Employee ID]
Subject: Your Leave Application dated [Date] for [DD/MM/YYYY] to [DD/MM/YYYY]
Dear [Employee Name],
Thank you for submitting your application for [Number] days of [Leave Type] from [DD/MM/YYYY] to [DD/MM/YYYY]. We have reviewed it carefully along with the team schedule for that period.
We regret that we are unable to approve the leave for these dates for the following reason:
Letter · Word
Leave Rejection Letter
Download .docx

Medical Certificate Submission Form

Preview of the form

A. Employee Details

B. Certificate Details

C. Documents Attached

D. For HR Use

What this template includes

When to use it

How to customise this template

HR tips

Frequently asked questions

Part A – Employee Details

Part B – Leave Details

Part C – Work Handover

Leave Application Form

Employee

Leave Requested

Leave Request Form

1. Employee Details

2. Leave Applied For

3. Leave Sanctioned

Leave Approval Form

1. Employee Details

2. Reason for Medical Leave

3. Leave Period and Leave Heads

Medical Leave Application

1. Employee Details

2. Leave Details

Return From Leave Form

A. Employee Details

B. Year-End Position

C. Employee Choice for Excess Earned Leave

Leave Carry Forward Form

1. Employee Details

2. Type of Adjustment

3. Entries to be Corrected

Leave Adjustment Form

Subject: Your Leave Application dated [Date] for [DD/MM/YYYY] to [DD/MM/YYYY]

Leave Rejection Letter

Medical Certificate Submission Form

Preview of the form

A. Employee Details

B. Certificate Details

C. Documents Attached

D. For HR Use

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