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CS Form No. 211 Revised 2018 Medical Certificate

This medical certificate form is used to document the results of pre-employment medical exams for prospective government employees. It requires a licensed government physician to examine the applicant, review test results like blood tests and x-rays, and determine if the applicant is physically fit for the proposed position. The form collects identifying and employment information about the applicant as well as the examining physician's determination and signature.

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Laureta Pascua
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20K views2 pages

CS Form No. 211 Revised 2018 Medical Certificate

This medical certificate form is used to document the results of pre-employment medical exams for prospective government employees. It requires a licensed government physician to examine the applicant, review test results like blood tests and x-rays, and determine if the applicant is physically fit for the proposed position. The form collects identifying and employment information about the applicant as well as the examining physician's determination and signature.

Uploaded by

Laureta Pascua
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
  • Instructions: Provides a set of instructions that detail how the medical certificate form should be completed and who it should be submitted to.
  • For the Licensed Government Physician: Includes fields intended for completion by the examining physician, which involve declarations regarding the physical examination and suitability for employment.
  • For the Proposed Appointee: Contains fields for personal information such as name, address, age, and the position for which the appointee is applying.

CS Form No.

211
Revised 2018

MEDICAL CERTIFICATE
(For Employment)

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/psychological
must be attached to this form:
Blood Test
Urinalysis
Chest X-Ray
Drug Test
Psychological Test
Neuro-Psychiatric Examination (if applicable)

F O R THE PRO PO SED APPO I NTEE


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 PHYSI CIAN

I hereby certify that I have reviewed and evaluated the attached examination results, personally examined
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)


Bare Foot Stripped

OFFICIAL DESIGNATION DATE EXAMINED


CAL CERTIFICATE
(For Employment)

STRUCTIONS

RO PO SED APPO I NTEE


AGENCY / ADDRESS

PROPOSED POSITION

ED GOVERNMENT PHYSI CIAN

valuated the attached examination results, personally examined the


physically and medically £FIT / £UNFIT for employment.

OTHER INFORMATION ABOUT THE


PROPOSED APPOINTEE

BLOOD
TYPE

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