CS Form No. 211 Revised 2018 MEDICAL CERTIFICATE (For Employment) INSTRUCTIONS 2. This medical certificate should be accomplished by a licensed government physician. b. Attach this certificate to orginal appointment, transfer and reemployment. «. The results ofthe following pre-employment medicaliphysical/psychological ‘must be attached to this form: 1 Blood Test Urinalysis Chest X-Ray Drug Test Psychological Test Neuro-Psychiatric Examination (f applicabl oon000t FOR THE PROPOSED APPOINTEE NAME (lat Nave, Frat Name, Name Exension (Vany) ara Meade Nara) [ADDRESS AGE SEX [ewit STATUS ~ PROPOSED POSITION FOR THE LICENSED GOVERNMENT PHYSICIAN J hereby certify that | have reviewed and evaluated the attached examination rasults, personally examined the labove named individual and found him/her to be physically and medically CIFIT / UNFIT for employment. [SIGNATURE over PRINTED NAME OF LICENSED GOVERNMENT PHYSICIAN: (OTHER INFORMATION ABOUT THE PROPOSED APPOINTEE IAGENCYIAfilaion of Licensed Government Physician 7 LICENSE NO, HEIGHT wy WEIGHT wa] BLOOD fare Foot | stipoee—|__ TYPE. [OFFICIAL DESIGNATION [DATE EXAMINED.