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.