CSC Form 211 (Revised August 1998)

MEDICAL CERTIFICATE
Form for Employment

PHILIPPINE CIVIL SERVICE

PHILIPPINE CIVIL SERVICE

MEDICAL CERTIFICATE FOR EMPLOYMENT
INSTRUCTIONS
1. This medical certificate should accomplished by the government physician.
2. Attach this certificate to original appointment and reinstatement.
NAME:
(Last)
(First)
(Middle)
:
AGENCY
Dep.Ed. Lanuza
ADDRESS
Zone 4, Lanuza,
BODE
ARNOLD
FELIX
CASANO
JUNE
PELISAN
DSDS
DEP ED
---------------------------------------------------------------------------------------- :
ADDRESS:
ZONE I, LANUZA, SURIGAO DEL SUR
---------------------------------------------------------------------------------------- :
PROPOSED
POSITION
AGE
:
SEX
:
CIVIL STATUS
:
29y.o.
3220
:
MALE MALE :
MARRIED
M:
----------------------------------------------------------------------------------------------- :------------------------Re-Employment Medical Physical Tests
1. / / Blood Test
2. / / Urinalysis
3. / / Chest X- Ray
4. / / Drug Test
5. / / Neuro Psychiatric Examination on (if necessary)
NOTE: ALL RESULTS OF EXAMINATIONS MUST BE ATTACHED TO THE FORM
I HEREBY CERTIFY that I personally examined the above named individual
and found him/her to be physically and mentally fit/unfit for employment.
PRINTED NAME OF PHYSICIAN : CERTIFICATE NO.: OTHER INFORMATION ABOUT
THE APPOINTEE

EMMANUEL H. ZARRAGA, M.D.:

:
_____________________________________________________________________________________
OFFICIAL DESIGNATION
: HEIGHT :
WEIGHT :
BLOOD TYPE
MUNICIPAL HEALTH OFFICER
AGENCY

:
:
: DATE EXAMINED

MUNICIPAL HEALTH OFFICE

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