Physician’s Certification Form

For the CFA® Program

FULL NAME AS SHOWN ON CFA INSTITUTE RECORDS

CFA INSTITUTE IDENTIFICATION #

EXAM DATE

By signing this form, I agree that I have provided truthful and accurate information regarding my deferral request. The information listed below, from my treating physician will confirm the
information I previously provided. I understand that providing false and/or inaccurate medical information may be deemed as a violation by our Professional Conduct department, result in
disciplinary sanction, and consequently impact future registrations.

CANDIDATE SIGNATURE DATE (DAY/MONTH/YEAR)

TO BE COMPLETED BY LICENSED PHYSICIAN

DATE OF EVALUATION

ILLNESS/CONDITION TREATED

Is this illness/condition life-threatening to the patient on the Exam Date (indicated above)? Please see Attachment A for a list of conditions that CFA Institute generally considers life
threatening.

YES

NO

I certify below that all of the above information is truthful and accurate and I understand that CFA Institute may contact me to verify all information included herein.

PHYSICIAN’S SIGNATURE DATE (DAY/MONTH/YEAR)

PRINTED FULL NAME

MEDICAL LICENSE/REGISTRATION NUMBER

DEGREE/SPECIALTY

ADDRESS CITY STATE COUNTRY

E-MAIL ADDRESS (MUST BE LEGIBLE TO ALLOW RECEIPT OF IMPORTANT COMMUNICATIONS)

TELEPHONE NUMBER (INCLUDE COUNTRY CODE, AREA OR CITY CODE , AND LOCAL)

Include official stamp of medical practice here if available:

Attachment A
To Physician’s Certification Form For the CFA® Program

Conditions considered life-threatening enough to Conditions considered not-life-threatening enough to

warrant deferral will often require hospitalization. warrant a deferral:
Examples of such conditions may include: Anxiety
Birth of child
Backache
Pregnancy complications that put mother or child Blisters/cuts/injuries to writing hand
at risk or in danger
Broken bones- limbs, toes, fingers
Acute blood clot
Carpel tunnel syndrome
Acute, unstable broken neck or back
Cold/bronchitis/upper respiratory infection
Heart attack, heart surgery
Community acquired pneumonia (unless hospitalized)
Severe depression/suicidal
Conjunctivitis
Psychosis
Fever (unknown origin)
Asthma (severe attack) on the day of exam
Food poisoning
Crohn’s disease flare-up
Gastroenteritis
Myocarditis
Headaches/migraines
Colitis
Hemorrhoids
Stroke, delirium, paralysis
Influenza without complications
Lasik eye surgery (elective)
Non-hospitalization conditions that may qualify:
Menstruation problems
Cancer (surgery, radiation, chemotherapy)
One-day illnesses of any type
Chicken pox
Panic attacks
Acute Hepatitis A or B
Pregnancy without complications
Malaria
Outpatient anticoagulation
Measles
Removal of teeth
Tuberculosis
Skin diseases (eczema, hives, itching)
Typhoid
Strep throat
Tonsillitis
Urinary tract infection
Virus/fever
Vomiting, nausea, and/or diarrhea (unless hospitalized)
Chronic compression fracture of the spine