Medical-Certificate-CS-Form-No.-211-Revised-2018.xls

	A	C	D	E	G	H	I
1	CS Form No. 211
2	Revised 2018
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4	MEDICAL CERTIFICATE
5	(For Employment)
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8	I N S T R U C T I O N S
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10		a. This medical certificate should be accomplished by a licensed government physician.
11		b. Attach this certificate to original appointment, transfer and reemployment.
12		c. The results of the following pre-employment medical/physical/psychological
13		must be attached to this form:
14			Blood Test
15			Urinalysis
16			Chest X-Ray
17			Drug Test
18			Psychological Test
19			Neuro-Psychiatric Examination (if applicable)
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22	F O R T H E P R O P O S E D A P P O I N T E E
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24	NAME (Last Name, First Name, Name Extension (if any) and Middle Name)				AGENCY / ADDRESS
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26	ADDRESS
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28	AGE	SEX		CIVIL STATUS	PROPOSED POSITION
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32	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
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34	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.
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38	SIGNATURE over PRINTED NAME OF LICENSED GOVERNMENT PHYSICIAN:				OTHER INFORMATION ABOUT THE PROPOSED APPOINTEE
39					OTHER INFORMATION ABOUT THE PROPOSED APPOINTEE
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41	AGENCY/Affiliation of Licensed Government Physician:
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43	LICENSE NO.				HEIGHT (M)	WEIGHT (KG)	BLOOD
44					Bare Foot	Stripped	TYPE
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46	OFFICIAL DESIGNATION				DATE EXAMINED
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