CS-Form-No.-211-Medical-Certificate.xls

	A	C	D	E	G	H	I
1	CS Form No. 211
2	Revised 2017
3
4
5	MEDICAL CERTIFICATE
6	(For Employment)
7
8
9
10	I N S T R U C T I O N S
11
12		a. This medical certificate should be accomplished by a licensed government physician.
13		b. Attach this certificate to original appointment, transfer and reemployment.
14		c. The results of the following pre-employment medical/physical/mental examinations
15		must be attached to this form:
16			Blood Test
17			Urinalysis
18			Chest X-Ray
19			Drug Test
20			Psychological Test
21			Neuro-Psychiatric Examination (if applicable)
22
23
24
25	F O R T H E P R O P O S E D A P P O I N T E E
26
27	NAME (Last Name, First Name, Name Extension (if any) and Middle Name)				AGENCY / ADDRESS
28
29	ADDRESS
30
31
32	AGE	SEX		CIVIL STATUS	PROPOSED POSITION
33
34
35
36	F O R T H E L I C E N S E D G O V E R N M E N T P H Y S I C I A N
37
38	I hereby certify that I have reviewed and evaluated the attached examination results, personally examined the above named individual and found him/her to be physically and medically £FIT / £UNFIT for employment.
39
41
42	SIGNATURE over PRINTED NAME OF LICENSED GOVERNMENT PHYSICIAN:				OTHER INFORMATION ABOUT THE PROPOSED APPOINTEE
43					OTHER INFORMATION ABOUT THE PROPOSED APPOINTEE
44
45
46	AGENCY/Affiliation of Licensed Government Physician:
47
48
49	LICENSE NO.				HEIGHT (M)	WEIGHT (KG)	BLOOD
50
51					Bare Foot	Stripped	TYPE
52
53	OFFICIAL DESIGNATION				DATE EXAMINED
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101