CSC FORM NO.

211 (1997)

MEDICAL CERTIFICATE

PHILIPPINE CIVIL SERVICE

FOR EMPLOYMENT

INSTRUCTION
1.THIS MEDICAL CERTIFICATE SHOULD BE ACCOMPLISHED BY GOVERNMENT PHYSICIANS.
2.ATTACHED THIS CERTIFICATE TO ORIGINAL APPOINTMENT AND REINSTATEMENTS.

NAME:

Last Name, First, Middle or if married woman, maiden name.

COLANGGO ARNEL PADILLA.

COMPRA, LILOY, ZAMBOANGA DEL NORTE

ADDRESS:

AGENCY:
DEP. ED

TEACHER 1

: PROPOSED POSITION
:

28

MALE

AGE:

MARRIED

SEX:

CIVIL STATUS:

PRE EMPLOYMENT MEDICAL PHYSICAL TESTS

1.
2.
3.
4.
5.

BLOOD TEST
URINALYSIS
CHEST X-RAY
DRUG TEST
NEURO-PSYCHIATRIC EXAMINATION(If necessary)

NOTE: ALL RESULTS OF EXAMINATION MUST BE ATTACHED TO THIS FORM

FOR THE PHYSICIAN

I HEREBY CERTIFY THAT I PERSONALLY

EXAMINED THE ABOVE-NAME INDIVIDUAL
AND FOUND HIM/HERE TO BE PHYSICALLY AND
MEDICALLY FIT/UNFIT FOR EMPLOYMENT
SIGNATURE OF PHYSICIAN
CERTIFICATE
NUMBER

AGENCY

:
:
:
:

DATE OF EXAMINATION

OTHER INFORMATION ABOUT

THE APPOINTEE