CSC Form 211 (Revised August 1998)

MEDICAL CERTIFICATE PHILIPPINE CIVIL SERVICE

For Employment

INSTRUCTIONS
1. This medical certificate should be accomplished by a government physician.
2. Attached this certificate to original appointment and reinstatement.

FOR THE PROPOSED APPOINTEE

Name: ( Last, Middle, or if Married woman, Maiden) AGENCY/ADDRESS:

ADDRESS: PROPOSED POSITION:

AGE: SEX: 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)

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

FOR THE PHYSICIAN

I hereby certify that I personally examined the above named

individual and found him/her to be physically and mentally fit/unfit Attach
for employment. Documentary Stamp
Here

PRINTED NAMES/SIGNATURE OF CERTIFICATE OTHER INFORMATION

PHYSICIAN: NUMBER ABOUT THE APPOINTEE

OFFICIAL DESIGNATION: HEIGHT: WEIGHT: Blood Type

(Bare Feet) (Stripped)

AGENCY: DATE EXAMINED: