Disclaimer:
- This is a sample for professional reference only. Modify as per your department's rules and current instructions.
- This is a sample format shared only for general guidance and professional reference. It must be filled with correct personal details, illness information, and medical documents as required by departmental rules.
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Purpose
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This application is used when an employee cannot attend duty due to illness, injury, or medical recovery. It officially informs the employer about the medical condition and seeks sanction of leave on medical grounds.
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Where to Submit
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- To the competent authority / head of office / appointing authority of your department.
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- Generally routed through the immediate superior.
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- In government offices, it goes to the Administration or HR/Establishment Section.
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- For PSU, bank, or school staff, submission is made to the Principal / HR Officer / Zonal Head, as applicable.
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Important Points
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- Submit the application as soon as illness occurs or within 48 hours of absence.
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- Attach a medical certificate from a registered medical practitioner (with registration number).
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- Mention exact dates of leave required.
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- If hospitalisation is involved, attach the hospital discharge summary.
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- Keep a copy of the application and acknowledgement for record.
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- Submit a fitness certificate before rejoining duty.
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- In long illnesses, submit periodic medical extensions.
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- Misrepresentation of illness can lead to disciplinary action.
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- Always check your department's leave rules for the number of medical leave days allowed.
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- Unused medical leave may be carried forward depending on policy.
Downloads & Resources
Legal Affidavit Document
To
The ___,
___,
___
Date: ___
Subject: Application for Medical Leave
Respected Sir/Madam,
I, ___, working as ___ in ___, am suffering from ___ and have been advised rest by a registered medical practitioner.
Accordingly, I request that I be granted medical leave for ___ days, i.e., from ___ to ___, under the applicable service rules. I am enclosing the medical certificate and fitness advice issued by my doctor in support of this application.
I shall resume duties as soon as I am declared fit to work and will submit the fitness certificate upon joining.
Kindly sanction the requested medical leave and oblige.
Thanking you,
Yours faithfully,
(Signature)
___
___
___
___
___
___
Enclosures:
- Medical certificate from registered medical practitioner – ___
- Fitness advice / prescription – ___
- Copy of previous leave record (if applicable) – ___
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