An application by a non-gazetted government servant in superior service for leave, or for an extension of leave, on medical certificate shall be accompanied by a medical certificate in the following form given by a registered medical practitioner or a government medical officer:Signature of applicant ..............I, .............. after careful personal examination of the case, hereby certify that----whose signature is given above is suffering from ............... The symptoms of the disease now present are ............... In my opinion the cause of the disease is ............... The duration of the disease reckoned to this date is .............. and the outline of the previous history of the disease ascertained from .............. is as follows:I consider that a period of absence from duty of .............. with effect from .............. is absolutely necessary for the restoration of his/her health.Note - (1) This form should be adhered to as closely as possible and should be filled in after the signature of the applicant has been taken. The certifying officer is not at liberty to certify that the applicant requires a change to or from a particular locality or that he is not fit to proceed to a particular locality. Such certificates should only be given at he explicit desire of the head of the office to whom it is open to decide when an application on such grounds has been made to him, whether the applicant should go before a medical board to decide the question of his fitness for service.Note - (2) The medical certificate and history of the case as also the second medical opinion (if any) prescribed in rule 96, should be prepared in duplicate, one copy of which the government servant proceeding on leave should take with him for presentation to the medical officer or committee who examines him for fitness before his return to duty.
