MEDICAL FITNESS - SELF DECLARATION& UNDERTAKIMG

I ......................................hereby make he e ara er ak re ar my hea h a me a b

Bank Limited. Istatethatthis declaration&undertaking be taken on record of the Bank. I state that I am making this declaration as a
pre-requisiteand as arequirement for taking up the employment with Csb Bank Limited. I state that Csb Bank Limited
shall be free andis herebyauthorized to usethisdeclaration&undertakingfor the purpose of and topreservein the record of the
Bank. I hereby authorize Csb Bank Limited to use thisdeclaration& undertakingandalso authorize Csb Bank Limited to
use theinformation contained herein for all purposes including contesting or denying any claim or allegations against any authority
of Csb Bank Limited, by using or quotingmy health condition. Thisdeclaration& undertaking
can also be used by Csb BankLimited to deny or refuse any claim or allegations which I or my family members ormylegal heirs
ordependents maymake against Csb Bank Limited or any officials.

Name (Mr./Mrs./Ms) :

Date of Birth : Age (in years) : Gender :

1. Height (cms) :
___________
2. Weight (kgs) :
___________
3. Identification mark :
a) _________________________________

b) _________________________________
4. Whether wearing spectacle? :
(Yes/Not)
If Yes, then please specify the power :
______________
Since when have you been wearing spectacles :
______________
5. Blood Group :
______________
6. Do you have any existing injury or pre-existing injury : Yes/No

7. Have you at any time suffered from any form of injury / : Yes/No
sickness which needed rest / recuperation for more
than15 days at a time, so far? (If yes, provide details of the
sickness)
8. Have you at any time suffered from any impediments : Yes/No
related to health i.e. physical & psychological conditions
which would interfere or impair your performance and
ability at work? (If Yes, please elaborate.)
9. Are you undergoing any medical treatment or would : Yes/No
need special attention/assistance?
(If yes, then provide particulars of the same.)
10. Did you have any form of serious illness in the past or do : Yes/No
you have one at present or have you undergone any
surgery in the past or do plan any in the future?
(If yes, then provide particulars of the same.)
11. Have you EVER HAD any of the following? Please mention Yes or No for all the questions below
(if yes, provide details of the same)
a) Stroke, epilepsy, fits, recurring headache, faint or other : Yes/No
deceases or disorders of brain, spinal-cord or nerves?
b) Depression, anxiety, or any other mental or nervous disorder? : Yes/No
c) Diabetes, thyroid disorders or any other hormone disorder? : Yes/No
d) Ear discharge, impaired sight, hearing or speech or any other : Yes/No
disorder of ear, eye, nose or throat?
e) Asthma, pneumonia, tuberculosis, emphysema, coughing up : Yes/No
blood, persistent cough, or any other disorder of the chest or

1 | P a g e Medical Fitness - Self-Declaration

 MEDICAL FITNESS - SELF DECLARATION& UNDERTAKIMG
lungs?
f) High or low blood pressure, increased or decreased : Yes/No
palpitations, chest pain, raised cholesterol, heart attack or any
other disorder of the heart or blood vessels?
g) Hepatitis (including Hepatitis carrier), liver disorder, gall : Yes/No
bladder disorder, ulcer, bleeding from the stomach or bowel,
hemorrhoids or any other disorder of the digestive track ?
h) Cancer, tumor, cyst or growth of any kind? : Yes/No
i) Anemia, hemophilia, leukemia or any blood disorder : : Yes/No
j) Back or neck complaint, arthritis, gout, physical disability or : Yes/No
other disorder of the bones joints or muscles?
k) Any illness that has caused you to be absent from work for : Yes/No
continuous period of 7 days or more ?
l) Have you been infected with HIV, been diagnosed as having : Yes/No
HIV antibodies or suffered from an AIDS related condition?
m) In the last 5 years have you attended doctor or any other : Yes/No
medical facility for investigation or diagnostic tests (such as X-
ray, ultrasound, CT scan, biopsy, ECG, blood or urine etc.)
n) Have you had any other illness, injury, operation or : Yes/No
abnormality not mentioned under any question above which is
recurrent?
0) Do you have any symptoms or condition for which you intend : Yes/No
to attend a doctor in the future?

Declaration

I, ………………………………………………………………, do hereby solemnly affirm that the information provided herein above is true and
correct in every respect and complete to the best of my knowledge and no information concerning my past or present state of
health has been withheld or concealed.

I, hereby declare that I ammedically fit and do not suffer from any serious illness or infection or any terminal or infectious disease at
the time of my appointment/employment with the Bank.

I hereby state and affirm that I have sound physical and mental health and I do not get impacted or influenced or affected by any
work related pressures or tensions. I hereby state and affirm that I am emotionally strong and do not succumb to any pressure
whatsoever. As such, I shall never make any allegations against the Bank about any such influence or impact or effect on me or on
my mental or physical health, any time,before any authority inside or outside Bank.

I hereby agree and also undertake to undergo any health assessment or medical examination by a medical practitioner, as and when
called upon or prescribed by the Bank, if deemed necessary by the Bank at any point of time before or after my appointment and
during the tenure of my appointment in the Bank.

I am conscious and aware that any incorrect/false or misleading information or suppression of information or material omission of
information about any of the question mentioned herein may make me ineligible for employment or if employed I would be liable to
be terminated or my appointment in the Bank / letter of appointment would be called back and that at the sole discretion of the
Bank, the Bank may be free to initiate disciplinary action against me, if need be, as deemed fit by the Bank.

Signature: ______________________

Date: __________________________

2 | P a g e Medical Fitness - Self-Declaration