Medical Certificate

State / District, ________

This is to certify that Mr. ________________________________ is local / non-local

person & resident of
(address proof is attached).

He has been thoroughly screened for COVID-19 by me on date /

/2020, is not showing any influenza/ ILI/SARI Like symptom of COVID-19 and
found any asymptomatic. So herewith mentioned person can work in essential
industries within this region by following all safety measures at work (i.e., Wear a
mask, maintaining social distance, sanitation of hands frequently, etc as per govt.
guidelines).

Date: - / /2020
Place: -

(Seal with signature)

(Registered Medical Practitioner)

(Registration Number ___________)

Following to be maintained by industries who are allowing him to work.

 Take employee’s temperature and assess symptoms prior to their entry in

industry.
 If an employee becomes sick during the day, send them home / hospital
immediately (based on need).
 Clean and disinfect all areas such as offices, bathrooms, work area & all
common areas.
 Increase the frequency of cleaning commonly touched surfaces.
 Self-Declaration by the Applicant

I Mr. ______________ ______ resident of __________________

________________________will abide by the standard health protocol
decided by the _________________state & ____________ District, else
I am aware that I may be penalized as per provision of the law, Including
sec 188, IPC & all other provisions

Date: - / /2020
Place: -

(Signature of Applicant)
Name: -