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CS Form No. 211 Medical Certificate

The document provides instructions for a prospective employee or faculty member at the University of the Philippines regarding their pre-employment physical and medical examination. It introduces the individual and refers them to the University Health Service, and requests notification of the examination results. It also lists documents and tests that must be submitted, such as urine and stool samples, past x-rays, and payment of fees. The medical certificate form collects information about the individual and requires certification by a licensed government physician of whether the person is physically and medically fit for the intended position based on the attached examination results.

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Marlene Salaum Magparoc
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813 views2 pages

CS Form No. 211 Medical Certificate

The document provides instructions for a prospective employee or faculty member at the University of the Philippines regarding their pre-employment physical and medical examination. It introduces the individual and refers them to the University Health Service, and requests notification of the examination results. It also lists documents and tests that must be submitted, such as urine and stool samples, past x-rays, and payment of fees. The medical certificate form collects information about the individual and requires certification by a licensed government physician of whether the person is physically and medically fit for the intended position based on the attached examination results.

Uploaded by

Marlene Salaum Magparoc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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UNIVERSITY OF THE PHILIPPINES

Diliman, Quezon City


HUMAN RESOURCES DEVELOPMENT OFFICE

Date

The Director
University Health Service
University of the Philippines
Diliman, Quezon City

Dear Director ______________________:

This is to introduce ________________________________________________ a


prospective employee/faculty in this University, whom we are referring to your office for
physical and medical examination. Position to be filled (Original/Permanent).

Please notify this Office as to the result of the examination. (Form Attached)

Very truly yours,

For the Director:

INSTRUCTION FOR PRE-EMPLOYMENT/PERMANENCY/PHYSICAL/MEDICAL


EXAMINATION

To facilitate the completion of your physical and medical examination, be


sure to submit as early as possible to the University Health Service the following:

1. Fresh specimen of
a) Urine
b) Feces

2. A certification of the last X-ray you had, if any


3. Medical Fee (For original/reappointment only)
CS Form No. 211
Revised 2017

MEDICAL CERTIFICATE
(For Employment)

INSTRUCTIONS
a. This medical certificate should be accomplished by a licensed government physician.
b. Attach this certificate to original appointment, transfer and reemployment.
c. The results of the following pre-employment medical/physical/mental examinations
must be attached to this form:
Blood Test
Urinalysis
Chest X-Ray
Drug Test
Psychological Test
Neuro-Psychiatric Examination (if applicable)

FOR THE PROPOSED APPOINTEE


NAME (Last Name, First Name, Name Extension (if any) and Middle Name) AGENCY / ADDRESS

ADDRESS

AGE SEX CIVIL STATUS PROPOSED POSITION

FOR THE LICENSED GOVERNMENT PHYSICIAN

I hereby certify that I have reviewed and evaluated the attached examination results, personally examined the
above named individual and found him/her to be physically and medically £FIT / £UNFIT for employment.
SIGNATURE over PRINTED NAME OF LICENSED GOVERNMENT PHYSICIAN: OTHER INFORMATION ABOUT THE
PROPOSED APPOINTEE

AGENCY/Affiliation of Licensed Government Physician:

LICENSE NO. HEIGHT (M) WEIGHT (KG) BLOOD


Bare Foot Stripped TYPE

OFFICIAL DESIGNATION DATE EXAMINED

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