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CSC FORM NO.

211 (Revised August 1998) PHILIPPINE CIVIL SERVICE


MEDICAL CERTIFICATE
For Employment
____________________________________________________________________________
INSTRUCTIONS
1. This medical certificate should be accomplished by a government physician.
2. Attached this certificate to original appointments and reinstatements.
____________________________________________________________________________
FOR PROPOSED APPOINTEE
Name(Last, First, Middle, or if married woman, Maiden Name) AGENCY/ADDRESS

ADDRESS

AGE SEX CIVIL STATUS PROPOSED POSITION

Pre-Employment Medical-Physical Tests


1. Blood Test
2. Urinalysis
3. Chest X-ray
4. Drug Test
5. Neuro-Psychiatric Examination (if necessary)

NOTE: ALL RESULTS OF EXAMINATIONS MUST BE ATTACHED TO THIS FORM


.
FOR THE PHYSICIAN

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

PRINTED NAME/SIGNATURE OF PHYSICIAN CERTIFICATE OTHER INFORMATION ABOUT


NUMBER THE PROPOSED APPOINTEE

OFFICIAL DESIGNATION

HEIGHT WEIGHT BLOOD


(Barefoot) (Stripped) (Type)

AGENCY DATE EXAMINED


REFERRAL SIP FOR MEDICAL CHECK UP /
CLERANCE

Date

The Consultant-on-duty
UP-PGH Health Service
UP Manila Unit

Referring Mr./Ms.
for medical check-up/evaluation for possible:

( ) employment/appointment as
( ) promotion to
( ) change of status from temporary to permanent

Thank you

Director
Human Resource Development Office