To be given to the individual CERTIFICATE OF MEDICAL EXAMINATION Form Approved

examined with a pre-addressed U.S. OFFICE OF PERSONNEL MANAGEMENT OMB No. 3206 - 0250
envelope marked
“Confidential - Medical”.

Privacy Act Statement

Solicitation of this information is authorized by Section 552a of Title 5, United States Code, regarding records maintained on
individuals; Section 3301 of Title 5, United States Code, regarding determination as to an individual's fitness for employment with
regard to age, health, character, knowledge and ability; and Section 3312 of Title 5 United States Code, regarding waiver of physical
qualifications for preference eligibles. This form is used to collect medical information about individuals who are incumbents of
positions in the Federal Government which require physical fitness testing and medical examinations, or individuals who have been
selected for such a position contingent upon successful completion of physical fitness testing and medical examinations as a condition
of their employment. The primary use of this information will be to determine the nature of a medical or physical condition that may
affect safe and efficient performance of the work described. Additional potential routine uses of this information include using it to
ensure fair and consistent treatment of employees and job applicants, to adjudicate requests to pass over preference eligibles, or to
adjudicate claims of discrimination under the Rehabilitation Act of 1973, as amended. Completion of this form is voluntary; however,
failure to complete the form may result in no further consideration of an applicant, or a determination that an employee is no longer
qualified for his or her position. In addition, incomplete, misleading, or untruthful information provided on the form may result in delays
in processing the form for employment, termination of employment, or criminal sanction.

Public Burden Statement

We estimate an average of two to three hours per response to complete, including the time for reviewing instructions,
getting needed information, and reviewing the completed form. Send comments regarding our estimate or any other
aspect of this form, including suggestions for reducing completion time, to the U.S. Office of Personnel Management
(OPM), Employee Services, Recruitment and Hiring, Hiring Policy, Attn: OMB Number (3206-0250), 1900 E Street, NW,
Washington, D.C. 20415. The OMB number, 3206-0250, is currently valid. OPM may not collect this information, and
you are not required to respond, unless this number is displayed.

Instructions
There are five parts in this form:

Part A - To be completed by applicant or employee. Signature of the applicant or employee certifies that the information
provided is complete and accurate; and that the applicant or employee consents to the release of the examination
results to the employing agency.

Part B - To be completed by the appointing officer before the medical examination: identifies the purpose of the examination;
the position title, series and grade; generally describes the position; and shows the specific functional requirements
and environmental factors that the work requires.

Part C - To be completed and signed by the examining physician, and returned to the employing agency in the pre-paid/pre-
addressed “Confidential-Medical” envelope provided. Access to protected health information may be restricted to the
agency medical officer in accordance with existing and applicable legal requirements.

Part D - To be completed by the agency medical officer who reviews the examination results and recommends action. Upon
completion of Part D, an agency medical officer forwards Parts A, B, D and E to the agency human resources officer. A copy
of the entire form, to include Part C, is retained in the medical record.

Part E - To be completed by the agency human resources officer in order to document the personnel action that is rendered. If
the examining physician/physician assistant/nurse practitioner or reviewing agency medical officer requires additional
space, he/she may add a page titled “See attached continuation with heading 'OF-178 Attachment: Worker Name ;
Date: '" , and create the attachment.

U.S. Office of Personnel Management Optional Form 178

Section 3301 of Title 5 United States Code April 2012
Title 5 CFR 339 Formerly SF 78
For Local Reproduction Only Page 1 of 7 Previous editions not useable
 To be given to the individual CERTIFICATE OF MEDICAL EXAMINATION Form Approved
examined with a pre-addressed U.S. OFFICE OF PERSONNEL MANAGEMENT OMB No. 3206 - 0250
envelope marked
“Confidential - Medical”.

Part A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE

1. Name (Last, First, Middle Initial)

2. Federal Employee Number 3. Sex 4. Birth Date (month, day, year)

Male
Female
5. Do you have any medical disorder or physical impairment which may interfere in any way with the full performance of duties shown in
Part B, Number 3?

Yes No

(If your answer is YES, explain in writing below, and verbally explain to the physician performing the examination)

6. Address (including City, State, Zip Code)

7. E-mail Address 8. Telephone Numbers (with Area Code)

9. Applicant or Employee Consent and Certification

I certify that all of the information I have provided on this form is complete and accurate to the best of my knowledge, and that submitting
information that is incomplete, misleading, or untruthful may result in termination, criminal sanctions, or delays in processing this form for
employment. Furthermore, consistent with the Privacy Act Statement, I authorize the release to my employing agency of all information
contained on this examination form and all other forms generated as a direct result of my examination.

10. Signature (Do not print) 11. Date (month, day, year)

Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

1. Purpose of examination 2. Position Title, Series, and Grade

Pre-placement
Other (Specify)

3. Brief description of what the position requires the employee to do.

U.S. Office of Personnel Management Optional Form 178

Section 3301 of Title 5 United States Code April 2012
Title 5 CFR 339 Formerly SF 78
For Local Reproduction Only Page 2 of 7 Previous editions not useable

Name: Last 4 digits of Social Security Number: Date:

 To be given to the individual CERTIFICATE OF MEDICAL EXAMINATION Form Approved
examined with a pre-addressed U.S. OFFICE OF PERSONNEL MANAGEMENT OMB No. 3206 - 0250
envelope marked
“Confidential - Medical”.

Part B. CONTINUED - TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

4. Check the box for each functional requirement in section 4a and each environmental factor in section 4b essential to the duties of this
position. List any additional essential factors in the blank spaces. Provide complete reference to applicable medical standards and
requirements in Block 4a and ensure the examining physician/physician assistant/nurse practitioner has immediate and complete
access to these materials when performing this assessment. If the position involves law enforcement, air traffic control, or firefighting,
attach the specific medical standards for the information of the examining physician.

4a. Functional Requirements

Heavy lifting, 45 pounds and over Repeated bending ( hours) Both eyes required
Moderate lifting, 15-44 pounds Climbing, legs only ( hours) Depth perception
Light lifting, under 15 pounds Climbing, use of legs and arms Ability to distinguish basic colors
Heavy carrying, 45 pounds and over Both legs required Ability to distinguish shades of colors
Moderate carrying, 15-44 pounds Operation of crane, truck, tractor, or motor Hearing (aid may be permitted)
Light carrying, under 15 pounds vehicle Hearing without aid
Straight pulling ( hours) Ability for rapid mental and muscular Specific hearing requirements (specify)
coordination simultaneously
Pulling hand over hand ( hours) Other (specify)
Ability to use and desirability of using
Pushing ( hours) firearms
Reaching above shoulder Near vision correctable at 13” to 16”
to Jaeger 1 to 4
Use of fingers
Far vision correctable in one eye to 20/20
Both hands required
and to 20/40 in the other
Walking ( hours)
Standing ( hours) Specific visual requirement (specify)

Crawling ( hours)
Kneeling ( hours)

4b. Environmental Factors

Outside Electrical energy Working alone

Outside and inside Slippery or uneven walking surfaces Protracted or irregular hours of work
Excessive heat Working around machinery with moving parts Other (specify)
Excessive cold Working around moving objects or vehicles
Excessive humidity Working on ladders or scaffolding
Excessive dampness or chilling Working below ground
Dry atmospheric conditions Unusual fatigue factors (specify)
Excessive noise, intermittent
Constant noise Working with hands in water
Dust Explosives
Silica, asbestos, etc. Vibration
Fumes, smoke, or gases Working closely with others
Solvents (degreasing agents)
Grease and oils
Radiant energy

U.S. Office of Personnel Management Optional Form 178

Section 3301 of Title 5 United States Code April 2012
Title 5 CFR 339 Formerly SF 78
For Local Reproduction Only Page 3 of 7 Previous editions not useable

Name: Last 4 digits of Social Security Number: Date:

 To be given to the individual CERTIFICATE OF MEDICAL EXAMINATION Form Approved
examined with a pre-addressed U.S. OFFICE OF PERSONNEL MANAGEMENT OMB No. 3206 - 0250
envelope marked
“Confidential - Medical”.

Part C. TO BE COMPLETED BY EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER. Final

examination results must be reviewed and certified by the Agency Medical Officer.
NOTE TO EXAMINING PHYSICIAN: The person you are about to examine will have to cope with the functional requirements and
environmental factors checked in Part 4 of this form. Please take these, and the brief description of the job duties, into consideration as
you make your examination and report your findings and conclusions.

1. Height Feet, Inches. Weight: Pounds.

2. Eyes:
20 20 20 20
a. Distant vision (Snellen): without corrective lenses: right left ; with corrective lenses, if worn; right left

b. Depth perception Type of test:

Seconds of Arc
Number correct: of tested
Interpretation Normal Abnormal
c. Peripheral vision Right Nasal degrees Temporal degrees
Left Nasal degrees Temporal degrees

d. What is the longest and shortest distance at which the following specimen of Jaeger No. 2 type can be read by the applicant?

Test each eye separately.

Jaeger No. 2 Type without corrective lenses: with corrective lenses, if used:
The President may -
(1) prescribe such regulations for the admission of L in. to in. L in. to in.
individuals into the civil service in the executive
branch as will best promote the efficiency of that R in. to in. R in. to in.
service; (2) ascertain the fitness of applicants as to
age, health, character, knowledge, and ability for the
employment sought; and (3) appoint and prescribe the
duties of individuals to make inquiries for the purpose
of this section.
(Title 5 U.S. Code 3301)

e. Color vision:
Is color vision normal by Ishihara or other color plate test? Yes No

If not, can applicant pass lantern test? Yes No

Can see red/green/yellow? Yes No

U.S. Office of Personnel Management Optional Form 178

Section 3301 of Title 5 United States Code April 2012
Title 5 CFR 339 Formerly SF 78
For Local Reproduction Only Page 4 of 7 Previous editions not useable

Name: Last 4 digits of Social Security Number: Date:

 To be given to the individual CERTIFICATE OF MEDICAL EXAMINATION Form Approved
examined with a pre-addressed U.S. OFFICE OF PERSONNEL MANAGEMENT OMB No. 3206 - 0250
envelope marked
“Confidential - Medical”.

Part C. TO BE COMPLETED BY EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER. Final

examination results must be reviewed and certified by the Agency Medical Officer
3. Ears: (Include certified audiogram results with the examination package).

Right Ear ; Left Ear

20 ft. 20 ft.

4. Other Findings: Describe any abnormality (including diseases, scars, and disfigurations). Include brief pertinent history. If normal,
so indicate.
a. Eyes, ears, nose, and throat (including tooth and oral hygiene)

b. Abdomen

c. Head and back (including face, hair, and scalp)

d. Peripheral blood vessels

e. Speech (note any malfunction)

f. Extremities (including strength, range of motion)

g. Skin and lymph nodes (including thyroid gland)

h. Urinalysis (if indicated)

SP. Gr. Sugar Blood Albumen

Casts Pus

i. Respiratory tract (X-ray if indicated)

j. Heart (size, rate, rhythm, function)

Blood pressure
Pulse
EKG (if indicated)

k. Back (special consideration for positions involving heavy lifting and other strenuous duties)

l. Neurological (including reflexes, sensation) and mental health

U.S. Office of Personnel Management Optional Form 178

Section 3301 of Title 5 United States Code April 2012
Title 5 CFR 339 Formerly SF 78
For Local Reproduction Only Page 5 of 7 Previous editions not useable

Name: Last 4 digits of Social Security Number: Date:

 To be given to the individual CERTIFICATE OF MEDICAL EXAMINATION Form Approved
examined with a pre-addressed U.S. OFFICE OF PERSONNEL MANAGEMENT OMB No. 3206 - 0250
envelope marked
“Confidential - Medical”.

Part C. TO BE COMPLETED BY EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER. Final

examination results must be reviewed and certified by the Agency Medical Officer
5. Conclusions: Summarize below any medical findings that in your opinion, would limit this person's ability to perform these job duties or
make them a hazard to themselves or others. If none, so indicate.

No limiting conditions for this job

Limiting conditions as follows:

6. Examining Physician's Name 7. E-Mail Address

8. Address (Including Street, City, State and ZIP Code) 9. Telephone Number

10. Signature of Examining Physician 11. Date (Month, Day, Year)

IMPORTANT: After signing, return the entire form intact in the pre-addressed “Confidential-Medical” envelope which the person you
examined gave you.

U.S. Office of Personnel Management Optional Form 178

Section 3301 of Title 5 United States Code April 2012
Title 5 CFR 339 Formerly SF 78
For Local Reproduction Only Page 6 of 7 Previous editions not useable

Name: Last 4 digits of Social Security Number: Date:

 To be given to the individual CERTIFICATE OF MEDICAL EXAMINATION Form Approved
examined with a pre-addressed U.S. OFFICE OF PERSONNEL MANAGEMENT OMB No. 3206 - 0250
envelope marked
“Confidential - Medical”.

FOR AGENCY USE ONLY

Part D. TO BE COMPLETED BY AGENCY MEDICAL OFFICER (if one is available)
NOTE: Review the attached certificate of medical examination and make your recommendations in item 1 below.
1. Recommendation:
Medically Qualified

Medically Qualified if restrictions accommodated (list restrictions)

Medically Disqualified

2. Agency Medical Officer's Name 3. E-Mail Address

4. Address (Including Street, City, State and ZIP Code) 5. Telephone Number

6. Signature of Agency Medical Officer 7. Date (Month, Day, Year)

FOR AGENCY USE ONLY

Part E. TO BE COMPLETED BY AGENCY HUMAN RESOURCES OFFICER
1. Action Taken:
Hired or Retained

Non-Selected for Appointment, or Eligibility Objected To

Action Taken to Separate

2. Agency Human Resources Officer's Name 3. E-Mail Address

4. Address (Including Street, City, State and ZIP Code) 5. Telephone Number

6. Signature of Agency Human Resources Officer 7. Date (Month, Day, Year)

Print Form Save Form Clear Form

U.S. Office of Personnel Management Optional Form 178

Section 3301 of Title 5 United States Code April 2012
Title 5 CFR 339 Formerly SF 78
For Local Reproduction Only Page 7 of 7 Previous editions not useable

Name: Last 4 digits of Social Security Number: Date: