CSC FORM NO.

211 (Revised August 1998) PHILIPPINE CIVIL SERVICE

MEDICAL CERTIFICATE
For Employment
1. This medical certificate should be accomplished by government physician.
2. Attached this certificate to original appointment and reinstatement.
NAME (Last, First, Middle or if married woman, maiden name)
ADDRESS
AGE SEX CIVIL STATUS
Pre-Employment Medical-Physcial Tests
1. Blood Test
2. Urinalysis
3. Chest X-Ray
4. Drug Test
5. Neuro-Physician Examination (if necessary)
NOTE: ALL RESULTS OF EXAMINATION MUST BE ATTACHED TO THIS FORM.
I hereby certify that I personally examined the above named AFFIX
individual and found him/her to be physically and medically Documentary
fit/unfit for employment. Stamps Here
PRINTED NAME/SIGNATURE OF PHYSICIAN CERTIFICATE NUMBER OTHER INFORMATION ABOUT
THE PROPOSED APPOINTEE
OFFICIAL DESIGNATION
AGENCY
DATE EXAMINED
FOR THE PHYSICIAN
HEIGHT WEIGHT BLOOD
I N S T R U C T I O N S
(Bare foot) (Stripped) Type
FOR THE PROPOSED APPOINTEE
PROPOSED POSITION
AGENCY/ADDRESS