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Form guide · Source checked 21 October 2026
ESIC Form 7: first, intermediate and final medical certificate
The combined Form7 has three selectable clinical stages; the PDF demonstrates a coherent first/intermediate/final sequence without issuing a real medical certificate.
Identified 1950 Regulations form / saved transition and online procedure; checked 21 October 2026
Download and read the completed example
Three hypothetical clinical-stage transcriptions for the same fictional viral-illness spell1–15 October2026. No real patient assessment, doctor signature, professional number or dispensary stamp is supplied.
Fictional, unsigned completed illustration. It demonstrates this form’s fields; it is not a filed return, medical opinion, official order or proof of an actual transaction.
When and how this form is used
Form7 replaced the older separate first/intermediate/final form numbers from1 January2005. Use its actual stage selection; a historical reference to old Form8/9/10 does not rename the current Form7 medical stages.
Under Regulation57, first certificate normally relates to examination day. Retrospection to the preceding day has the stated beyond-control/IMO-satisfaction condition. A first-and-final certificate can specify fitness no later than the third day after examination.
Regulation59 requires intermediate certificates at intervals not exceeding7 days unless Regulation61’s special longer-period conditions apply. Regulation58’s final fitness date cannot be later than the third day after examination. The illustrated1→8→15 October examinations have7-day gaps and16 October fitness.
Submit each issued certificate within3 days under Regulation64 to avoid the specified possible loss of benefit; bona fide relaxation is a decision of the competent office. The model’s submission dates2,9 and16 October are all one day after issue. Obtain the final certificate before working for wages.
The completed fields
First certificate: actual prescribed fields
| Prescribed field / section | Completed fictional entry |
|---|---|
| Book / serial / dispensary stamp | DEMO-BOOK [synthetic]; F-01 [synthetic]; dispensary stamp not executed |
| First certificate date / employee / parent / IP | 1 October2026; Ravi Kumar, son of Meera Kumar; [synthetic IP DEMO-0001; not a valid insurance number] |
| Employer / Branch Office | [synthetic employer code DEMO-ESI; not valid]; appropriate Branch Office, New Delhi |
| Examination / opinion / diagnosis | 1 October2026; Select branch(i): needs treatment and abstention from work because of fictional viral illness. Branches(ii)/(iii) not selected; no final fitness certified. |
| Other remarks / medical attestation | No additional remark; hypothetical IMO only. A real authorised medical professional must examine/certify; Unsigned fictional teaching entry; signature, seal, photograph attestation and official issue NOT executed |
| Patient signature / IMO name / signature / stamp | Ravi Kumar signature/thumb impression not executed; illustrative clinician name Dr Fictional Medical Officer, not a real professional/registration; all execution absent |
Intermediate certificate: actual prescribed fields
| Prescribed field / section | Completed fictional entry |
|---|---|
| Book / serial / dispensary stamp | DEMO-BOOK [synthetic]; I-01 [synthetic]; dispensary stamp not executed |
| First certificate date / employee / parent / IP | 1 October2026; Ravi Kumar, son of Meera Kumar; [synthetic IP DEMO-0001; not a valid insurance number] |
| Employer / Branch Office | [synthetic employer code DEMO-ESI; not valid]; appropriate Branch Office, New Delhi |
| Examination / opinion / diagnosis | 8 October2026; Select branch(ii): continued treatment and abstention through8 October due to the same fictional illness. First certificate1 October;7 elapsed days. Branches(i)/(iii) not selected. |
| Other remarks / medical attestation | No additional remark; hypothetical IMO only. A real authorised medical professional must examine/certify; Unsigned fictional teaching entry; signature, seal, photograph attestation and official issue NOT executed |
| Patient signature / IMO name / signature / stamp | Ravi Kumar signature/thumb impression not executed; illustrative clinician name Dr Fictional Medical Officer, not a real professional/registration; all execution absent |
Final certificate: actual prescribed fields
| Prescribed field / section | Completed fictional entry |
|---|---|
| Book / serial / dispensary stamp | DEMO-BOOK [synthetic]; Z-01 [synthetic]; dispensary stamp not executed |
| First certificate date / employee / parent / IP | 1 October2026; Ravi Kumar, son of Meera Kumar; [synthetic IP DEMO-0001; not a valid insurance number] |
| Employer / Branch Office | [synthetic employer code DEMO-ESI; not valid]; appropriate Branch Office, New Delhi |
| Examination / opinion / diagnosis | 15 October2026; Select branch(ii) continued incapacity through15 October and branch(iii) fit to resume16 October2026, one day after examination; no work before final fitness. |
| Other remarks / medical attestation | No additional remark; hypothetical IMO only. A real authorised medical professional must examine/certify; Unsigned fictional teaching entry; signature, seal, photograph attestation and official issue NOT executed |
| Patient signature / IMO name / signature / stamp | Ravi Kumar signature/thumb impression not executed; illustrative clinician name Dr Fictional Medical Officer, not a real professional/registration; all execution absent |
Supporting records and reconciliation
Genuine examination and authorised IMO opinion; actual certificate book/serial, diagnosis, stage, interval and fitness; insured-person identity, employer/Branch details, timely submission receipts and separate Form9 claim/abstention verification where required.
Worked calculation: 1→8 October=7 days;8→15=7;15→16 fitness=1≤3. Illustrative submission each next day=1≤3.
Official source and version
Download the official source pages containing this form. Adjacent prescribed forms can share a source page; use the heading and rule identified above.
These are the identified ESI (General) Regulations 1950 forms and the online procedures described by ESIC. Code on Social Security section164(2)(b) saves the earlier ESI rules/regulations for one year from commencement to the extent consistent. The 13 July 2026 instrument published in Gazette274902 is expressly a DRAFT inviting objections; it cannot by itself substitute these forms. The examples are source-checked on 21 October 2026 within the identified transition, not a claim that an old paper layout is the current portal screen.
Practical questions
Can I submit the sample as my own completed form?
No. Replace the fictional facts with accurate records, use the competent filing or record-keeping route described above and complete genuine signatures or certifications where required.
What makes the example specific to this form?
The combined Form7 has three selectable clinical stages; the PDF demonstrates a coherent first/intermediate/final sequence without issuing a real medical certificate.