Certificate
FORM A
Certificate by a registered medical practitioner showing whether a person examined by him has or has not consumed an intoxicant.
See rule 3
What this form is for
Form A is a medical certificate recording whether a person examined at a hospital or dispensary has consumed alcohol, opium, charas, ganja or bhang, and whether he is under the influence of alcohol. It is completed and signed by the registered medical practitioner who conducts the clinical examination of a person brought in by a police or prohibition officer. It also notes whether blood was collected for chemical testing. The form is prescribed under rule 3 of the Bombay Prohibition (Medical Examination and Blood Test) Rules, 1959.
Form text (extracted)
9931949 : Bom. XXV] Bombay Prohibition Act, 1949
5.Certificate of test of sample blood.––The Testing Officer shall on receipt of the
sample blood, test it and shall certify the result of his test in Form ‘C.’ The Testing Officer
shall send the certificate in duplicate to the registered medical practitioner by whom the
blood was forwarded to him for test and retain a copy thereof on his record.On receipt of
the certificate from the Testing Officer, the registered medical practitioner shall forward the
original copy of the certificate to the Police Officer or the Prohibition Officer concerned.The
duplicate copy of the certificate shall be kept by him on his record.
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FORM ‘A’
(See rule 3)
Certificate by a registered medical practitioner showing whether a person examined by
him has or has not consumed an intoxicant.
Serial No. . . . . . . . . . . . . . . . . . . . . .(Name and location of the
Dispensary or Hospital)
Certified that Shri/Smt./Kumari. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
of . . . . . . . . . . . . . . . . . . . . . . . was brought to this hospital/dispensary by . . . . . . . . . . . . . . .
.. . . . . . . . . . . . . . . . . . . .(here state name and designation of the Officer) on. . . . . . . . . . . . . .
20at. . . . . . . . . . . . . . . . a. m./p. m. and was examined by me on. . . . . . . . . . . . . . . . . . . . .
20at . . . . . . . . . . . . . . . .a. m. /p. m.
A clinical examination of the above-named person disclosed the following :
Age . .
Weight . .
Smelling.
Breath . . Not smelling
alcohol/opium/charas/ganja/bhang
Incoherent
Speech . . Normal
Unsteady
Gait . . Steady
Dilated
Pupils . . Normal
additional remarks, if any.
I find that the above named person
has
consumed alcohol/opium/charas/ganja/bhang.
has not consumed any intoxicant.
I also find that he
is
under the influence of alcohol.
is not
994 Bombay Prohibition Act, 1949 [1949 : Bom. XXV
was
N. B.–– (Blood from the body of the above named ———— collected by me for
chemical examination).
was not
Dated . . . . . . . . . . . . . .20. (Signature) . . . . . . . . . . . . . . . .
Designation. . . . . . . . . . . . . . . .
Signature/Thumb-impression of the
person examined.
Marks of identification of the person
examined in case he refuses to give his
signature or thumb-impression.
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FORM ‘B’
[See rule 4 (2)]
No. . . . . . . . . . . . . . . . . . . . .
From
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Name , designation and address of the registered medical practitioner.)
To,
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Name , designation and address of the Testing Officer. )
Dated . . . . . . . . . . . . . . . . .20.
Sir,
I, forward herewith by post/with Shri* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
of . . . . . . . . . . . . . . . . . . . . . . . a phial bearing serial No. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .
containing. . . . . . . . . . . . . . c. c. o. venous blood collected by me on. . . . . . . . . . . . . . . . . . . .
at. . . . . . . . . . . . . . . . . . . . . . . . . . .a.m./p.m. of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . who was
produced before me for medical examination †and/or collection of blood from his/her
body ‡ by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . and request
you to test the blood and issue a certificate (in duplicate) regarding the result of the test.
Yours faithfully,
Signature and designation of the
registered medical practioner.
Facsimile of the seal or monogram used for
sealing the phial containing the blood.
* Here specify the name, designation and address of the messenger with whom the phial containing the
blood is forwarded for delivery to the Testing Officer.
† Strike off, if these words are not required.
‡ Here state the name and designation of the officer by whom the said person was produced for
collection of blood.
Original PDF (as scanned from printed manual)