CSC FORM NO.

211(1997)
MEDICAL CERTIFICATE For Employment

PHILIPPINE CIVIL SERVICE INSTRUCTIONS

1. This medical certificate should be accomplished by a government physician. 2. Attached this certificate to original appointment and reinstatement. ______________________________________________________________________________ NAME (Last, First, Middle or if married woman, AGENCY Maiden Name) 1 ______________________________________________________ ADDRESS ______________________________________________________ AGE SEX _____________________ PROPOSED POSITION
______________________

CIVIL STATUS

_______________________ _____________________________ _____________________ Pre-Employment Medical - Physical Tests 1. Blood test 2. Urinalysis 3. Chest X-ray 4. Drug test 5. Neuro Psychiatric Examination (if necessary) NOTE: ALL RESULTS OF EXAMINATIONS MUST BE ATTACHED TO THIS FORM FOR THE PHYSICIAN I HEREBY CERTIFY that I personally examined the above-mentioned individual and found him/her to be physically and normally fit/unfit for employment. SIGNATURE OF PHYSICIAN CERTIFICATE NUMBER Affix Documentary stamp

Other information about the appointee:

OFFICIAL DESIGNATION

HEIGHT (Bare feet)

WEIGHT (Stripped)

AGENCY

DATE EXAMINED