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Return-to-Work Medical Clearance

The return-to-work medical clearance confirms an employee is fit to resume duty after a long illness, injury, surgery or hospitalisation, and records any modified duties or phased return. The treating doctor completes the fitness part, and HR and the manager agree a practical plan for the first few weeks back.

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[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]

Restriction	Details	Until
Lifting / carrying	[Max weight in kg]	[DD/MM/YYYY]
Standing / walking	[Hours]	[DD/MM/YYYY]
Night shift / overtime	[Not permitted / Permitted]	[DD/MM/YYYY]
Driving / machine operation	[Not permitted / Permitted]	[DD/MM/YYYY]
Travel	[Details]	[DD/MM/YYYY]

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

Part C – Phased Return Plan (Manager and HR)

Week	Hours / Day	Duties	Check-in Date
Week 1	[Number]	[Modified duties]	[DD/MM/YYYY]
Week 2	[Number]	[Modified duties]	[DD/MM/YYYY]
Week 3	[Number]	[Duties]	[DD/MM/YYYY]
Week 4	[Number]	[Normal duties]	[DD/MM/YYYY]

Can the restrictions be accommodated in the current role? (Yes / No)
If no, alternative role or arrangement
Review date to remove restrictions

Declaration

I agree to the return-to-work plan above and will inform my manager or HR if I experience difficulty performing my duties.

Employee
[Employee Name]
Date: [Date]

Reporting Manager
[Reporting Manager]
Date: [Date]

HR
[HR Name]
Date: [Date]

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What this template includes

Absence details and reason category (without diagnosis)
Doctor's fitness to resume with date
Restrictions: lifting, standing, shifts, driving, travel
Phased return plan with hours per week
Manager's confirmation that restrictions can be met
Review date to lift restrictions

When to use it

An employee returns after sick leave longer than your policy threshold
Resuming after a workplace injury or accident
Returning after surgery, maternity complications or hospital admission
Before a driver or machine operator resumes a safety-critical task

How to customise this template

1Set the sick-leave threshold that triggers this form in your leave policy
2Add your company medical officer's review step for safety-critical roles
3Use the phased-return table to agree reduced hours
4Record whether the absence was ESI-covered for benefit reconciliation
5Attach the doctor's original fitness certificate

HR tips

Have a welcome-back conversation, not just paperwork
Do not ask for the diagnosis; ask for capability
Check in at the end of week one and week four
Reassess the workstation or task if the injury was work-related

Leave, ESI benefits and fitness requirements depend on your leave policy, standing orders and applicable laws; ensure reasonable adjustments are considered, and review with HR policy owners or a legal adviser.

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Frequently asked questions

When is a fitness certificate needed to rejoin after sick leave?+

Most companies ask for one after sick leave beyond a set number of days, and always after hospitalisation or a work injury. State the threshold in your leave policy.

Can the employee return to light duties?+

Yes, if the doctor advises restrictions and the manager can offer suitable modified work. The form records what is agreed and for how long.

Who issues the return-to-work clearance?+

The treating doctor certifies fitness; for safety-critical roles the company medical officer may also review before the employee resumes.

All 50 posh, workplace safety & compliance →

[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
Download .docx

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]

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

Download .docx

[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

Download .docx

[Company Logo][Company Name]
POLICY ON PREVENTION OF SEXUAL HARASSMENT (POSH)
Policy No.:
[Reference Number]
Version:
[Version Number]
Effective Date:
[Date]
Policy Owner:
Human Resources / Internal Committee
1. Purpose
[Company Name] is committed to a workplace free of sexual harassment. This policy is framed under the Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013 and its Rules, to prevent sexual harassment and provide a fair redressal mechanism.
2. Scope
It applies to all employees, interns, trainees, consultants, contract staff and visitors at all locations of the company, including [Work Location]. 'Workplace' includes offices, sites, company transport, places visited during work, and work-related online spaces. As company policy, [the protections are extended to employees of all genders].
3. Definitions
Policy · Word
POSH Policy
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[Company Logo][Company Name]

ORDER CONSTITUTING THE INTERNAL COMMITTEE

Ref. No.:: [Reference Number]
Date:: [Date]
Effective From:: [DD/MM/YYYY]
Applicable To:: [Work Location / All Locations]

[Company Name]
[Company Address]

Subject: Constitution of the Internal Committee under the Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013

In accordance with the Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013 and the rules framed under it, the management of [Company Name] hereby constitutes the Internal Committee (IC) for [Work Location / All Locations] with effect from [DD/MM/YYYY]. The committee shall receive and inquire into complaints of sexual harassment at the workplace and recommend action in a fair, timely and confidential manner.

Role	Name	Designation / Organisation	Phone	Email
Presiding Officer	[Member Name]	[Designation] (senior woman employee)	[Phone]	[Email]
Member	[Member Name]	[Designation]	[Phone]	[Email]
Member	[Member Name]	[Designation]	[Phone]	[Email]
External Member	[Member Name]	[NGO / Organisation Name]	[Phone]	[Email]

Tenure

Notice · Word

POSH Committee Constitution Letter

Download .docx

[Company Logo][Company Name]
APPOINTMENT AS PRESIDING OFFICER – INTERNAL COMMITTEE
Ref. No.:
[Reference Number]
Date:
[Date]
To,
[Employee Name]
[Designation], [Department]
Employee ID: [Employee ID]
[Work Location]
Subject: Appointment as Presiding Officer of the Internal Committee
Dear [Employee Name],

We are pleased to inform you that the management of [Company Name] has appointed you as the Presiding Officer of the Internal Committee constituted under the Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013, vide order no. [Reference Number] dated [Date]. This appointment recognises your seniority, integrity and the trust that colleagues place in you.
Your Responsibilities
1. Chair meetings of the Internal Committee and ensure the required quorum is present.
2. Receive complaints, guide complainants on the process and record them properly.
3. Lead inquiries in line with principles of natural justice, giving both parties a fair hearing.
4. Consider requests for conciliation where the complainant asks for it, without monetary settlement.
5. Ensure the inquiry is completed within [Number] days or the period prescribed under current rules.
6. Sign and submit the inquiry report and recommendations to the employer.
7. Contribute to the annual report and awareness programmes.
Letter · Word
Internal Committee Appointment Letter
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[Company Logo][Company Name]
APPOINTMENT AS MEMBER – INTERNAL COMMITTEE
Ref. No.:
[Reference Number]
Date:
[Date]
Member Category:
[Employee Member / External Member]
To,
[Member Name]
[Designation / Organisation Name]
[Address]
Subject: Nomination as Member of the Internal Committee
Dear [Member Name],

With reference to the order constituting the Internal Committee of [Company Name] (Ref. [Reference Number], dated [Date]), we are pleased to nominate you as a member of the committee for [Work Location / All Locations] under the Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013.
For employee members: You have been nominated in view of your commitment to the cause of women, and your experience in [social work / legal knowledge / employee relations]. Committee work will be treated as part of your official duties.

For the external member: You have been nominated in view of your association with [NGO / Organisation Name] and your familiarity with issues relating to sexual harassment. You will be paid an honorarium of ₹[Amount] per sitting along with reimbursement of travel expenses of up to ₹[Amount], payable within [Number] days of each sitting.
Terms of Membership
Letter · Word
POSH Committee Member Appointment
Download .docx
[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
Download .docx

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)

Return-to-Work Medical Clearance

Preview of the form

Part A – Employee and Absence Details (HR)

Part B – Medical Clearance (Treating Doctor)

Part C – Phased Return Plan (Manager and HR)

Declaration

What this template includes

When to use it

How to customise this template

HR tips

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Frequently asked questions

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