FORM B
[Rule 4(1)]
MEDICAL CERTIFICATE

This is to certify that I examined ____________ wife/daughter of ____________ a woman employee in __________ (name of 3[mine or circus]) 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/has under gone miscarriage/3[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/delivery/premature birth of a child or miscarriage/3[medical termination of pregnancy of tubectomy operation].
 Signature, qualifications and designation of Medical Officer/Medical Practitioner
Date _________
Definitions of "child" and "miscarriage" as in the Maternity Benefit Act, 1961-
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. 
3. Inserted by GSR 70(E), dated 31st. January, 1996, w.e.f.1st. February, 1996.