Fill online: Annual health examination: notice to employees and the record

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Your details

Name of the establishment

Fills 3 places in the document.

Address of the establishment

OSH registration number

Calendar year of the examination

Fills 3 places in the document.

Date of the notice

Qualifying age in years

Date on which age is reckoned

Other employees or classes of work covered

Name and designation of the HR contact

Name and address of the examining facility

First day of the examination period

Last day of the examination period

Days of advance notice of the slot

ESIC facility, where the examination is arranged through ESIC

Age from which an ECG is done

Process-specific test

Employees in the process or area concerned

Basis for the process-specific test

Telephone and e-mail of the HR contact

Name of the authorised signatory

Designation of the authorised signatory

Date of display of the notice

Languages of display

Date the notice was sent to employees

Name of the employee

Employee code

Age of the employee

Designation of the officer who holds health records

Retention period for health records

Name and e-mail of the person handling data grievances

Date of the employee's consent

Name of the HR officer receiving the form

Date the form was received

Date of declining

Employee code and name, employee 1

Age and DOB, employee 1

Department and nature of work, employee 1

Date of examination, employee 1

Fit / Fit with restrictions / Temporarily unfit / Referred / Declined (1)

Date certificate given, employee 1

Follow-up required, employee 1

Date follow-up closed, employee 1

Employee code and name, employee 2

Age and DOB, employee 2

Department and nature of work, employee 2

Date of examination, employee 2

Fit / Fit with restrictions / Temporarily unfit / Referred / Declined (2)

Date certificate given, employee 2

Follow-up required, employee 2

Date follow-up closed, employee 2

Employee code and name, employee 3

Age and DOB, employee 3

Department and nature of work, employee 3

Date of examination, employee 3

Fit / Fit with restrictions / Temporarily unfit / Referred / Declined (3)

Date certificate given, employee 3

Follow-up required, employee 3

Date follow-up closed, employee 3

Employee code and name, employee 4

Age and DOB, employee 4

Department and nature of work, employee 4

Date of examination, employee 4

Fit / Fit with restrictions / Temporarily unfit / Referred / Declined (4)

Date certificate given, employee 4

Follow-up required, employee 4

Date follow-up closed, employee 4

Employee code and name, employee 5

Age and DOB, employee 5

Department and nature of work, employee 5

Date of examination, employee 5

Fit / Fit with restrictions / Temporarily unfit / Referred / Declined (5)

Date certificate given, employee 5

Follow-up required, employee 5

Date follow-up closed, employee 5

Employee code and name, employee 6

Age and DOB, employee 6

Department and nature of work, employee 6

Date of examination, employee 6

Fit / Fit with restrictions / Temporarily unfit / Referred / Declined (6)

Date certificate given, employee 6

Follow-up required, employee 6

Date follow-up closed, employee 6

Employee code and name, employee 7

Age and DOB, employee 7

Department and nature of work, employee 7

Date of examination, employee 7

Fit / Fit with restrictions / Temporarily unfit / Referred / Declined (7)

Date certificate given, employee 7

Follow-up required, employee 7

Date follow-up closed, employee 7

Employee code and name, employee 8

Age and DOB, employee 8

Department and nature of work, employee 8

Date of examination, employee 8

Fit / Fit with restrictions / Temporarily unfit / Referred / Declined (8)

Date certificate given, employee 8

Follow-up required, employee 8

Date follow-up closed, employee 8

Days to issue the certificate

Days to adjust work after a restriction

Days within which a referral is followed up

Days to consider reasonable accommodation

Date by which the offer is repeated

Number of employees eligible

Number of employees examined

Number of employees who declined

Number found fit

Number fit with restrictions

Number temporarily unfit

Number referred

Number of follow-up items open

Work-related factors identified

Name of the officer who prepared the summary

Date of the annual summary

Name of the reviewer

Designation of the reviewer

Date of review of the summary

Notice to employees, consent and privacy notice, record of examinations and follow-up · run once in every calendar year

[Name of the establishment]
Establishment: [Address of the establishment] | Registration number under section 3, OSH Code 2020: [OSH registration number]

Who must be examined. Section 6(1)(c) of the OSH Code requires the employer to provide, free of cost, an annual health examination or test for employees of the age, and in the class of establishments, prescribed by the appropriate Government. Where the Central Government is the appropriate Government, Rule 5(1) of the OSH (Central) Rules 2026 applies it to dock work, mines and building and other construction work, for employees who have completed 40 years of age; the examination is by a qualified medical practitioner, who gives a certificate in Form VIII to both the employer and the employee (Rule 5(2)), and the employer may arrange it through ESIC facilities. Mine workers have additional tests under the rules, which this format does not cover. For factories, shops, offices and other establishments in the State sphere, the State OSH rules decide the age (some States use 45 years), the classes covered, the timing and the certificate form. Where no rule covers the establishment, adopt this as a policy benefit on the same terms.

Statutory medical surveillance of workers in a hazardous process, pre-employment examinations and fitness examinations for particular jobs are separate requirements. Do not merge them into this annual examination.

Part 1. Notice to employees

NOTICE: ANNUAL HEALTH EXAMINATION, [Calendar year of the examination]

Date of notice: [Date of the notice]

1. Who is eligible. Every employee of [Name of the establishment] (the "Company") who has completed [Qualifying age in years] years of age on or before [Date on which age is reckoned] is entitled to a free annual health examination. Also covered: [Other employees or classes of work covered]. The list of eligible employees is with [Name and designation of the HR contact] and on the notice board. If you are eligible and not on the list, tell HR.

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