Rule Form X Form X
- Chapter
- Annexures · Forms and Appendices
- Text as on
- As notified 08 May 2026
FORM -- X [See rule 35(1)(a), 35(1)(d) and 35(2)(f)] Certificate of Medical Officer/Medical Practitioner for confinement/miscarriage/ Medical termination of pregnancy or tubectomy operation/ delivery of a child
This is to certify that-
1. *I examined.......wife/ daughter of ..... a woman employee in...... (Name of the establishment) on...... (Date) and found/ cannot discover that she is pregnant and is expected to be delivered of a child within (month and/days) from the above mentioned date or has undergone miscarriage/ Medical termination of pregnancy or tubectomy operation/has been delivered of a child on......... (Date) or is suffering from.........(date) from illness arising out of pregnancy or delivery or premature birth of a child or miscarriage/ Medical termination of pregnancy or tubectomy operation.
2. *Smt......... wife/daughter of......... employed in...... (Name of the establishment) expired on ......before/during/ after confinement. The child died on......or survives her.
3. *I examined....wife/ daughter of....a woman employed in............ (Name of establishment) and found that she has been delivered of a child or has undergone miscarriage on......... (date).
*Strike out unnecessary portion.
Signature and designation of
Medical Officer/Medical Practitioner/ASHA/ANM/Gram Pradhan/Village Administrative Officer/
Authorised Officer of the Municipality
Date.........
Definitions of "child" and "miscarriage" as in the Code on Social Security, 2020(36 of 2020).-
1. "Child" includes a still-born child.
2. "Miscarriage" means expulsion of the contents of a pregnant uterus at any period prior to or
during the twenty-sixth week of pregnancy but does not include any miscarriage, the causing of which
is punishable under the Indian Penal Code.