Docstoc

Medical Certificate Form - Excel

Document Sample
Medical Certificate Form - Excel Powered By Docstoc
					CSC FORM NO. 211 (Revised August 1998)
MEDICAL CERTIFICATE                                                              PHILIPPINES CIVIL SERVICE
For Employment

                                           INSTRUCTIONS

NAME ( Last, First, Middle, or if married woman, Maiden Name)

                                                                                    AGENCY / ADDRESS
ADDRESS

AGE                 SEX                    CIVIL STATUS                            PROPOSED POSITION


                    Pre-Employment Medical - Physical Test

                    1. Blood Test
                    2. Urinalysis
                    3. Chest X-Ray
                    4. Drug Test
                    5. Neuro-Phychiatric Examination (If necessary)

NOTE: ALL RESULTS OF EXAMINATIONS MUST BE ATTACHED TO THE FORM.

                                            FOR THE PHYSICIAN


    I hereby certify that I have personally examined the above named                              AFFIX
individual and found her / him to be physically and medically fit / unfit for                  Documentary
employment.                                                                                    Stamp Here

                                                                                 OTHER INFORMATION ABOUT
PRINTED NAME / SIGNATURE OF PHYSICIAN: CERTIFICATE NUMBER                        THE PROPOSED APPOINTEE



OFFICIAL DESIGNATION
                                                                                HEIGHT WEIGHT           BLOOD
                                                                                Bared Foot   Stripped    Type
AGENCY
                                                                                DATE EXAMINED

				
DOCUMENT INFO
Description: Medical Certificate Form document sample