This medical certificate form is to be completed by a government physician for individuals being considered for employment or reinstatement. It requires basic personal information about the applicant as well as the results of various medical and physical tests, including blood tests, urinalysis, chest x-rays, and drug tests. The examining physician must then certify whether the applicant is physically and medically fit or unfit for the proposed position.

1. 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
I hereby certify that I have personally examined the
abovementioned individual and found her/him, to be physically
and medically fit/unfit for employment.
PRINTED NAME/SIGNATURE OF PHYSICIAN CERTIFICATE
NUMBER
OTHER INFORMATION ABOUT
THE PROPOSED APPOINTEE
OFFICIAL DESIGNATION
HEIGHT
(Barefoot)
WEIGHT
(Stripped)
BLOOD
(Type)
AGENCY DATE EXAMINED