Civil Service Commision Form 211(1997)

MEDICAL CERTIFICATE
( For Employment)
PHILIPPINE SERVICE COMMISION
INSTRUCTIONS
1. This medical cerficate should be accomplished by a government physician.
2. Attached this certificate to original appointment and reinstatement.
FOR THE PROPOSED APPOINTEE
NAME (Last, First, Middle of if married women, Maiden Name)
AGENCY

ADDRESS

AGE

PROPOSED POSITION

SEX

CIVIL STATUS

Pre -Employment Medical-Physical Tests

1. Blood Test
2. Urinalysis
3. Chest X-ray
4. Drug test
5. Neuro Psychiatric Exam (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 named
AFFIX
individual and found him/her to be pyhsically and mentally fit/unfit for
DOCU ENTARY
employment.
STAMP
SIGNATURE OF PHYSICIAN
CERTIFICATE NUMBER
OTHER INFORMATION ABOUT
THE APPOINTEE
OFFICIAL DESIGNATION
HEIGHT WEIGHT
BLOOD TYPE
(Bare Feet) (Stripped)
AGENCY

DATE SIGNED

physician.
ment.