No. 6/1/2021-CS-II(C)
Government of India
Ministry of Personnel, Public Grievances & Pensions
(Department of Personnel and Training)

$3^{\text {rd }}$ Floor, Lok Nayak Bhavan
Khan Market, New Delhi
Dated $17^{\text {T }}$ February, 2021
To
The CMO/ Civil Surgeon
Officer-in-Charge ((Medical Examination-I)
Dr. RML Hospital, New Delhi-110001
Subject: Medical Examination of candidates for appointment to the Grade of Stenographer Grade ‘D’ of CSSS on the basis of result of Stenographers’ Grade ‘C’ \& ‘D’ Examination, 2018.

Sir/Madam,
I am directed to refer to the subject mentioned above and to say that the candidates recommended for appointment to the grade of Stenographer Grade ‘D’ of Central Secretariat Stenographers’ Service (CSSS) in Government of India, on the basis of Stenographers’ Grade ‘C’ \& ‘D’ Examination, 2018 are required to appear before Medical Board for their medical examination.
2. The candidates (as per list attached) are being instructed through this letter to appear before you for medical examination in OPD Block, Dr. Ram Manohar Lohia Hospital, New Delhi for the date of medical examination before 02.03.2021. List of the candidates is enclosed herewith. It is requested that the candidates may be medically examined and the Medical Certificate be forwarded to this Department in the prescribed format by 04.03.2021.
3. The signature of the candidate may please be obtained on the prescribed format in your presence.

Yours faithfully
Encl.: As above

Bhagirath Jha

(Bhagirath Jha)
Under Secretary to the Government of India
Tele: 24654020

Copy to: Candidates as per list attached.

FORM OF MEDICAL CERTIFICATE

I hereby certify that I have examined $\mathrm{Sh} / \mathrm{Smt} / \mathrm{Km}$. $\qquad$ a candidate for employment in the Central Secretariat Service in the Government of India and cannot discover that he/she has any disease (communicable or otherwise), constitutional weakness or bodily infirmity, except $\qquad$ .

I do not consider this a disqualification for employment in Central Secretariat Service in the Government of India.

The age of Shri/Smt./Kum. $\qquad$ according to his/her own statement is $\qquad$ years, and by appearance is about $\qquad$ years.
(Signature/thumb impression of the candidate)

Date $\qquad$
(To be signed in the presence of the examining Medical Officer)

Signature of Medical Officer
Name $\qquad$
Address $\qquad$
Official Seal
(Seal should be spread over form and the photograph)

Note: The officer making this certificate should be a Civil Surgeon or a District Medical Officer of equivalent status of a Government Hospital

CANDIDATE’S STATEMENT AND DECLARATION

(The candidate must make the following statement and must sign the declaration below it before the medical officer. Attention is specially invited to the WARNING in the ‘Note’ at the bottom of page 2.)

1. Name in full
   (in BLOCK letters)
2. Age and place of birth
3. Have you ever had
   (a)small-pox, intermittent fever and other fever, enlargement suppuration of glands, spitting of blood, fainting attacks, rheumatism or appendicitis? OR
   (b) any other disease or accident requiring confinement to bed and medical or surgical treatment?
4. When were you last vaccinated?
5. Have you or any of your relatives been afflicted by consumption, scrofula, gout, asthma, fits, epilepsy or insanity?
6. Have you suffered from any form of nervousness due to overwork or any other cause?
7. Have you been examined and declared fit for Govt. Service by a medical officer/ Medical Board within the last three years?
8. Furnish the following particulars:

DECLARATION

I declare that all the above answers are true and correct to the best of my knowledge and belief. I also solemnly affirm that I have not received any disability certificate/ pension on account of any disease or other condition.

Candidate’s signature
Date: $\qquad$
Signed in my presence.

Signature of Medical Officer
Name: $\qquad$
\& Designation: $\qquad$
$\qquad$
$\qquad$

Note: The candidate will be held responsible for the accuracy of the above statement. By wilfully suppressing any information he will incur the risk of losing the appointment and, if appointed, of forfeiting all claims to superannuation allowance or gratuity.