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Employment Medical Certificate Form

The document is a medical certificate form (CS Form No. 211) required for employment, to be filled out by a licensed government physician. It includes instructions for completion, necessary medical examinations, and personal details of the proposed appointee, Rovelina Flores, who is applying for a Teacher I position. The physician must certify the individual's fitness for employment based on the attached examination results.

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Rovelyn Flores Furatero
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26 views2 pages

Employment Medical Certificate Form

The document is a medical certificate form (CS Form No. 211) required for employment, to be filled out by a licensed government physician. It includes instructions for completion, necessary medical examinations, and personal details of the proposed appointee, Rovelina Flores, who is applying for a Teacher I position. The physician must certify the individual's fitness for employment based on the attached examination results.

Uploaded by

Rovelyn Flores Furatero
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd

CS Form No.

211
Revised 2018

MEDICAL CERTIFICATE
(For Employment)

INSTRUCTIONS
a. This medical certificate should be accomplished by a licensed government physician.
b. Attach this certificate to original appointment, transfer and employment.
c. The results of the following pre-employment medical/physical/mental examinations
must be attached to this form.
Blood Test
Urinalysis
Chest X-Ray
Drug Test
Psychological Test
Neuro-Psychiatric Examination (if applicable)

FOR THE PROPOSED APPOINTEE


NAME (Last Name, First Name, Name Extension (if any) and Middle Name) AGENCY / ADDRESS

FURATERO ROVELYN FLORES


ADDRESS DEPARTMENT OF EDUCATION

LASERNA, NABAS, AKLAN


AGE SEX CIVIL STATUS PROPOSED POSITION

24 FEMALE MARRIED TEACHER I

FOR THE LICENSED GOVERNMENT PHYSICIAN


I hereby certify that I have reviewed and evaluated the attached examination reslts, personally examined the above
named individual and found him/her to be physically and medically FIT / UNFIT for employment.
SIGNATURE over PRINTED NAME OF LICENSED GOVERNMENT PHYSICIAN: OTHER INFORMATION ABOUT THE
PROPOSED APPOINTEE

AGENCY/Affiliation of Licensed Government Physician:

LICENSE NO. HEIGHT (M) WEIGHT (KG) BLOOD

Bare Foot
Stripped TYPE

1.47m 46kg O+
OFFICIAL DESIGNATION DATE EXAMINED

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