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CS Form No. 211

MEDICAL CERT

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Ann Rose Pelayo
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29 views

CS Form No. 211

MEDICAL CERT

Uploaded by

Ann Rose Pelayo
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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CS Form No.

211
Revised 2018

MEDICAL CERTIFICATE

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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