CSC Form 211 (Revised August 1998) PHILIPPINE CIVIL SERVICEMEDICAL CERTIFICATEForm for Employment

PHILIPPINE CIVIL SERVICEMEDICAL 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 ADDRESS

CASANO JUNE PELISAN D DEP ED---------------------------------------------------------------------------------------- :ADDRESS:

ZONE I, LANUZA, SURIGAO DEL SUR ---------------------------------------------------------------------------------------- : PROPOSED POSITIONAGE : SEX : CIVIL STATUS :

3220 y.o. : MALE MALE : MARRIED M:----------------------------------------------------------------------------------------------- :--------------------------

Re-Employment Medical – Physical Tests

1. / / Blood Test2. / / Urinalysis3. / / Chest X- Ray4. / / Drug Test5. / / 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 : _______

BODE ARNOLD FELIX

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Dep.Ed. LanuzaZone 4, Lanuza, SDS