Medical Certificate
2
CSC FORM NO. 211 (Revised August 1998) MEDICAL CERTIFICATE PHILIPPINES CI For Employment I N S T R U C T I O N S NAME ( Last, First, Middle, or if married woman, Maiden Name) AGENCY / ADD ADDRESS AGE SEX CIVIL STATUS PROPOSED POSI 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 PRINTED NAME / SIGNATURE OF PHYSICIAN: CERTIFICATE NUMBER OFFICIAL DESIGNATION HEIGHT WEIGHT Bared Foot Stripped AGENCY DATE EXAMINED I hereby certify that I have personally examined the above named individual and found her / him to be physically and medically fit / unfit for employment. AFFIX Documen Sta OTHER INFORMATION PROPOSED APPOI
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Transcript of Medical Certificate
CSC FORM NO. 211 (Revised August 1998)MEDICAL CERTIFICATE PHILIPPINES CIVIL SERVICEFor Employment
I N S T R U C T I O N S
NAME ( Last, First, Middle, or if married woman, Maiden Name)
AGENCY / ADDRESSADDRESS
AGE SEX CIVIL STATUS PROPOSED POSITION
Pre-Employment Medical - Physical Test
1. Blood Test2. Urinalysis3. Chest X-Ray4. Drug Test5. Neuro-Phychiatric Examination (If necessary)
NOTE: ALL RESULTS OF EXAMINATIONS MUST BE ATTACHED TO THE FORM.
FOR THE PHYSICIAN
PRINTED NAME / SIGNATURE OF PHYSICIAN: CERTIFICATE NUMBER
OFFICIAL DESIGNATIONHEIGHT WEIGHT BLOODBared Foot Stripped Type
AGENCYDATE EXAMINED
I hereby certify that I have personally examined the above named individual and found her / him to be physically and medically fit / unfit for employment.
AFFIX Documentary
Stamp Here
OTHER INFORMATION ABOUT THE PROPOSED APPOINTEE
