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Pre-Employment Medical Form

The pre-employment medical form is the full examination record used by the company's doctor or empanelled clinic before a selected candidate joins. It combines a self-declared health questionnaire, physical examination, job-specific tests and the doctor's fitness opinion, and becomes the baseline for later periodic exams.

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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)

Height (cm) / Weight (kg) / BMI
Blood Pressure
Pulse
Vision – distant / near (with / without glasses)
Colour vision
Hearing (clinical)
Respiratory system
Cardiovascular system
Musculoskeletal system
Skin

Part 4 – Job-Specific Tests

Test	Required for Role	Result	Remarks
Audiometry	[Yes / No]	[Result]	[Remarks]
Spirometry (lung function)	[Yes / No]	[Result]	[Remarks]
Chest X-ray	[Yes / No]	[Result]	[Remarks]
Blood tests (CBC / sugar)	[Yes / No]	[Result]	[Remarks]
Stool / sputum (food handlers)	[Yes / No]	[Result]	[Remarks]

Part 5 – Doctor's Opinion

Fit for the job offered
Fit with restrictions / adjustments: [Details]
Temporarily unfit – re-examine on [DD/MM/YYYY]
Unfit for the job offered (reasons explained to candidate)

Consent and Declaration

I declare that the information I have provided is true and complete to the best of my knowledge. I consent to this examination and to the doctor sharing only the fitness opinion and any work restrictions with [Company Name]. I understand detailed results will remain confidential.

Candidate
[Candidate Name]
Date: [Date]

Examining Doctor
Dr. [Doctor Name]
Reg. No. [Registration Number]
Seal and Signature

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What this template includes

Candidate consent to examination and limited sharing of results
Health questionnaire covering relevant history
Vitals, vision and hearing tests
Job-specific test table (spirometry, audiometry, colour vision, blood tests)
Doctor's fitness opinion with restrictions
Baseline note for future surveillance

When to use it

After selection and before joining, as mentioned in the offer letter
For roles exposed to noise, dust, chemicals, heat or heights
For drivers, forklift operators and crane operators
To create a health baseline for later periodic medical exams

How to customise this template

1Select tests by job role; avoid testing everyone for everything
2Get your doctor to approve the questionnaire
3Remove questions not relevant to the job to respect privacy
4Send the form to the empanelled clinic with the candidate
5File the completed form in the confidential medical file, not the HR file

HR tips

Schedule the exam after the offer, not as an early screening tool
Explain to candidates why each test is needed
Look for reasonable adjustments before declaring a candidate unfit
Do not ask about pregnancy or unrelated conditions

Pre-employment medical requirements and permitted tests depend on the OSH Code, 2020 rules, your industry and anti-discrimination laws such as the Rights of Persons with Disabilities Act, 2016; review with your medical officer and legal adviser.

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Frequently asked questions

What tests are done in a pre-employment medical?+

Usually general examination, vitals, vision and basic blood and urine tests, plus job-specific tests such as audiometry for noisy areas or spirometry for dusty processes.

Can an employer withdraw an offer based on the medical?+

Only where the condition genuinely prevents the person from doing the job safely even with reasonable adjustments. Take medical and legal advice before withdrawing an offer.

Who pays for the pre-employment medical?+

Many employers pay or reimburse the cost. State the arrangement in the offer letter.

All 50 posh, workplace safety & compliance →

[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

Form · Word

Annual Medical Examination 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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[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
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[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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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)

Name (optional)
Department
Role level (Staff / Supervisor / Manager)
Employee or contract staff

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)

[Company Logo][Company Name]

RETURN-TO-WORK MEDICAL CLEARANCE

Ref. No.:: [Reference Number]
Date:: [Date]

Part A – Employee and Absence Details (HR)

Employee Name
Employee ID
Designation
Department
Reporting Manager
Absence from [DD/MM/YYYY] to [DD/MM/YYYY]
Reason category (illness / injury at work / injury outside work / surgery / other)
ESI covered (Yes / No)

Part B – Medical Clearance (Treating Doctor)

I have examined [Employee Name] on [DD/MM/YYYY] and, considering the job demands described by the employer as [job demands], certify that the employee is:

Fit to resume full duties from [DD/MM/YYYY]
Fit to resume with restrictions listed below from [DD/MM/YYYY]
Not yet fit; review on [DD/MM/YYYY]

Form · Word

Return-to-Work Medical Clearance

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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

Pre-Employment Medical Form

Preview of the form

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

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

Part 3 – Clinical Examination (Doctor)

Part 4 – Job-Specific Tests

Part 5 – Doctor's Opinion

Consent and 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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