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Medical Certificate CSC Form 211

This medical certificate form is for employment in the Philippine Civil Service. It requires information about the applicant such as name, address, proposed position, age, sex, and civil status. It also lists required medical-physical tests including blood test, urinalysis, chest x-ray, and drug test. The examining physician must certify whether the applicant is physically and mentally fit for employment and attach all examination results to the form.

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3K views

Medical Certificate CSC Form 211

This medical certificate form is for employment in the Philippine Civil Service. It requires information about the applicant such as name, address, proposed position, age, sex, and civil status. It also lists required medical-physical tests including blood test, urinalysis, chest x-ray, and drug test. The examining physician must certify whether the applicant is physically and mentally fit for employment and attach all examination results to the form.

Uploaded by

arnoldfelixbode
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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CSC Form 211 (Revised August 1998)

MEDICAL CERTIFICATE
Form for Employment

PHILIPPINE CIVIL SERVICE

PHILIPPINE CIVIL SERVICE


MEDICAL CERTIFICATE FOR EMPLOYMENT
INSTRUCTIONS
1. This medical certificate should accomplished by the government physician.
2. Attach this certificate to original appointment and reinstatement.
NAME:
(Last)
(First)
(Middle)
:
AGENCY
Dep.Ed. Lanuza
ADDRESS
Zone 4, Lanuza,
BODE
ARNOLD
FELIX
CASANO
JUNE
PELISAN
DSDS
DEP ED
---------------------------------------------------------------------------------------- :
ADDRESS:
ZONE I, LANUZA, SURIGAO DEL SUR
---------------------------------------------------------------------------------------- :
PROPOSED
POSITION
AGE
:
SEX
:
CIVIL STATUS
:
29y.o.
3220
:
MALE MALE :
MARRIED
M:
----------------------------------------------------------------------------------------------- :------------------------Re-Employment Medical Physical Tests
1. / / Blood Test
2. / / Urinalysis
3. / / Chest X- Ray
4. / / Drug Test
5. / / Neuro Psychiatric Examination on (if necessary)
NOTE: ALL RESULTS OF EXAMINATIONS MUST BE ATTACHED TO THE FORM
I HEREBY CERTIFY that I personally examined the above named individual
and found him/her to be physically and mentally fit/unfit for employment.
PRINTED NAME OF PHYSICIAN : CERTIFICATE NO.: OTHER INFORMATION ABOUT
THE APPOINTEE

EMMANUEL H. ZARRAGA, M.D.:


:
_____________________________________________________________________________________
OFFICIAL DESIGNATION
: HEIGHT :
WEIGHT :
BLOOD TYPE
MUNICIPAL HEALTH OFFICER
AGENCY

:
:
: DATE EXAMINED

MUNICIPAL HEALTH OFFICE

_______

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