Fillable Printable Certificate of Medical Examination - U. S. Office of Personnel Management

Certificate of Medical Examination - U. S. Office of Personnel Management

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved

OMB No. 3206 - 0250

To be given to the individual

examined with a pre-addressed

envelope marked

“Confidential - Medical”.

U.S. Office of Personnel Management

Section 3301 of Title 5 United States Code

Title 5 CFR 339

For Local Reproduction Only

Optional Form 178

July 2009

Formerly SF 78

Previous editions not useable

Page 1 of 8

Instructions

There are five parts in this form:

Part A - To be completed by applicant or employee. Signature of the applicant or employee certifies that the information

provided is complete and accurate; and that the applicant or employee consents to the release of the

examination results to the employing agency.

Part B - To be completed by the appointing officer before the medical examination: identifies the purpose of the

examination; the position title, series and grade; generally describes the position; and shows the specific

functional requirements and environmental factors that the work requires.

Part C - To be completed and signed by the examining physician, and returned to the employing agency in the pre-paid/

pre-addressed “Confidential-Medical” envelope provided.

Part D - To be completed by the agency medical officer who reviews the examination results and recommends action.

Part E - To be completed by the agency human resources officer in order to document the personnel action that is

rendered.

Privacy Act Statement

Solicitation of this information is authorized by Section 552a of Title 5, United States Code, regarding records maintained

on individuals; Section 3301 of Title 5, United States Code, regarding determination as to an individual's fitness for

employment with regard to age, health, character, knowledge and ability; and Section 3312 of Title 5 United States Code,

regarding waiver of physical qualifications for preference eligibles. This form is used to collect medical information about

individuals who are incumbents of positions in the Federal Government which require physical fitness testing and medical

examinations, or individuals who have been selected for such a position contingent upon successful completion of

physical fitness testing and medical examinations as a condition of their employment. The primary use of this information

will be to determine the nature of a medical or physical condition that may affect safe and efficient performance of the

work described. Additional potential routine uses of this information include using it to ensure fair and consistent

treatment of employees and job applicants, to adjudicate requests to pass over preference eligibles, or to adjudicate

claims of discrimination under the Rehabilitation Act of 1973, as amended. Completion of this form is voluntary; however,

failure to complete the form may result in no further consideration of an applicant, or a determination that an employee is

no longer qualified for his or her position. In addition, incomplete, misleading, or untruthful information provided on the

form may result in delays in processing the form for employment, termination of employment, or criminal sanction.

Public Burden Statement

We estimate an average of two to three hours per response to complete, including the time for reviewing instructions,

getting needed information, and reviewing the completed form. Send comments regarding our estimate or any other

aspect of this form, including suggestions for reducing completion time, to the U.S. Office of Personnel Management

(OPM), Strategic Human Resources Policy, Medical Policy and Programs Division, Attn: OMB Number (3206-0250),

1900 E Street, NW, Washington, D.C. 20415. The OMB number, 3206-0250, is currently valid. OPM may not collect this

information, and you are not required to respond, unless this number is displayed.

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved

OMB No. 3206 - 0250

To be given to the individual

examined with a pre-addressed

envelope marked

“Confidential - Medical”.

U.S. Office of Personnel Management

Section 3301 of Title 5 United States Code

Title 5 CFR 339

For Local Reproduction Only

Optional Form 178

July 2009

Formerly SF 78

Previous editions not useable

Page 2 of 8

Part A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE

1. Name (Last, First, Middle Initial)

2. Federal Employee Number 3. Sex

4. Birth Date (month, day, year)

Male

Female

5. Do you have any medical disorder or physical impairment which would interfere in any way with the full performance of the duties

shown in Part B, No. 3?

YesNo

(If your answer is YES, explain fully to the physician performing the examination)

6. Address (including City, State, Zip Code)

7. E-mail Address 8. Telephone Numbers (with Area Code)

9. Applicant or Employee Consent and Certification

I certify that all of the information I have provided on this form is complete and accurate to the best of my knowledge, and that submitting

information that is incomplete, misleading, or untruthful may result in termination, criminal sanctions, or delays in processing this form for

employment. Furthermore, consistent with the Privacy Act Statement, I authorize the release to my employing agency of all information

contained on this examination form and all other forms generated as a direct result of my examination.

10. Signature (Do not print)

11. Date (month, day, year)

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved

OMB No. 3206 - 0250

To be given to the individual

examined with a pre-addressed

envelope marked

“Confidential - Medical”.

U.S. Office of Personnel Management

Section 3301 of Title 5 United States Code

Title 5 CFR 339

For Local Reproduction Only

Optional Form 178

July 2009

Formerly SF 78

Previous editions not useable

Page 3 of 8

Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

1. Purpose of examination 2. Position Title, Series, and Grade

Pre-placement

Other (Specify)_____________________________

3. Brief description of what the position requires the employee to do.

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved

OMB No. 3206 - 0250

To be given to the individual

examined with a pre-addressed

envelope marked

“Confidential - Medical”.

U.S. Office of Personnel Management

Section 3301 of Title 5 United States Code

Title 5 CFR 339

For Local Reproduction Only

Optional Form 178

July 2009

Formerly SF 78

Previous editions not useable

Page 4 of 8

Part B. CONTINUED - TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

4. Check the box for each functional requirement in section 4a and each environmental factor in section 4b essential to the duties of this

position. List any additional essential factors in the blank spaces. Also, if the position involves law enforcement, air traffic control, or

fire fighting, attach the specific medical standards for the information of the examining physician.

4a. Functional Requirements

Heavy lifting, 45 pounds and over

Moderate lifting, 15-44 pounds

Light lifting, under 15 pounds

Heavy carrying, 45 pounds and over

Moderate carrying, 15-44 pounds

Light carrying, under 15 pounds

Straight pulling (_____ hours)

Pulling hand over hand (_____ hours)

Pushing (_____ hours)

Reaching above shoulder

Use of fingers

Both hands required

Walking (______ hours)

Standing (______ hours)

Crawling (______ hours)

Kneeling (______ hours)

Repeated bending (______ hours)

Climbing, legs only (______ hours)

Climbing, use of legs and arms

Both legs required

Operation of crane, truck, tractor, or motor

vehicle

Ability for rapid mental and muscular

coordination simultaneously

Ability to use and desirability of using

firearms

Near vision correctable at 13” to 16”

to Jaeger 1 to 4

Far vision correctable in one eye to 20/20

and to 20/40 in the other

Specific visual requirement (specify)

______________________________

Both eyes required

Depth perception

Ability to distinguish basic colors

Ability to distinguish shades of colors

Hearing (aid permitted)

Hearing without aid

Specific hearing requirements (specify)

Other (specify)

________________________________

4b. Environmental Factors

Outside

Outside and inside

Excessive heat

Excessive cold

Excessive humidity

Excessive dampness or chilling

Dry atmospheric conditions

Excessive noise, intermittent

Constant noise

Dust

Silica, asbestos, etc.

Fumes, smoke, or gases

Solvents (degreasing agents)

Grease and oils

Radiant energy

Electrical energy

Slippery or uneven walking surfaces

Working around machinery with moving parts

Working around moving objects or vehicles

Working on ladders or scaffolding

Working below ground

Unusual fatigue factors (specify)

______________________________

Working with hands in water

Explosives

Vibration

Working closely with others

Working alone

Protracted or irregular hours of work

Other (specify)

________________________________

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved

OMB No. 3206 - 0250

To be given to the individual

examined with a pre-addressed

envelope marked

“Confidential - Medical”.

U.S. Office of Personnel Management

Section 3301 of Title 5 United States Code

Title 5 CFR 339

For Local Reproduction Only

Optional Form 178

July 2009

Formerly SF 78

Previous editions not useable

Page 5 of 8

Part C. TO BE COMPLETED BY EXAMINING PHYSICIAN

NOTE TO EXAMINING PHYSICIAN: The person you are about to examine will have to cope with the functional requirements and

environmental factors checked in Part 4 of this form. Please take these, and the brief description of the job duties, into consideration as

you make your examination and report your findings and conclusions.

1. Height ________ Feet, ________ Inches. Weight: ________ Pounds.

2. Eyes:

20 20 20 20

a. Distant vision (Snellen): without corrective lenses: right ____ left ____ ; with corrective lenses, if worn; right ____ left ____

b. Depth perception Type of test: _____________________________

___________ Seconds of Arc

Number correct: _____ of _____ tested

Interpretation

c. Peripheral vision Right Nasal ______ degrees Temporal ______ degrees

Left Nasal ______ degrees Temporal ______ degrees

d. What is the longest and shortest distance at which the following specimen of Jaeger No. 2 type can be read by the applicant?

Test each eye separately.

without corrective lenses: with corrective lenses, if used:

L ______in. to _____ in. L _____ in. to _____ in.

R______ in. to _____ in. R _____ in. to_____ in.

e. Color vision: Is color vision normal by Ishihara or

other color plate test?

If not, can applicant pass lantern test?

Can see red/green/yellow?

NormalAbnormal

Jaeger No. 2 Type

The President may -

(1) prescribe such regulations for the admission of

individuals into the civil service in the executive

branch as will best promote the efficiency of that

service; (2) ascertain the fitness of applicants as to

age, health, character, knowledge, and ability for the

employment sought; and (3) appoint and prescribe the

duties of individuals to make inquiries for the purpose

of this section.

(Title 5 U.S. Code 3301)

YesNo

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved

OMB No. 3206 - 0250

To be given to the individual

examined with a pre-addressed

envelope marked

“Confidential - Medical”.

U.S. Office of Personnel Management

Section 3301 of Title 5 United States Code

Title 5 CFR 339

For Local Reproduction Only

Optional Form 178

July 2009

Formerly SF 78

Previous editions not useable

Page 6 of 8

Part C. CONTINUED - TO BE COMPLETED BY EXAMINING PHYSICIAN

3. Ears: (Consider denominators indicated here as normal. Record as numerators the greatest distance heard.)

Ordinary conversation:

Right Ear _____ ;

20 ft.

Left Ear _____

20 ft.

Audiometer in dB (if given) for Right Ear:

250 5001000 2000300040005000600070008000

Audiometer in dB (if given) for Left Ear:

25050010002000300040005000600070008000

4. Other Findings: Describe any abnormality (including diseases, scars, and disfigurations). Include brief pertinent history. If normal,

so indicate.

a. Eyes, ears, nose, and throat (including tooth and oral hygiene)

b. Abdomen

c. Head and back (including face, hair, and scalp)

d. Peripheral blood vessels

e. Speech (note any malfunction)

f. Extremities (including strength, range of motion)

g. Skin and lymph nodes (including thyroid gland)

h. Urinalysis (if indicated)

SP. Gr. __________ Sugar __________ Blood __________

Albumen __________ Casts __________ Pus __________

i. Respiratory tract (X-ray if indicated)

j. Heart (size, rate, rhythm, function)

Blood pressure ______________

Pulse _______________

EKG (if indicated)

k. Back (special consideration for positions involving heavy lifting and other strenuous duties)

l. Neurological (including reflexes, sensation) and mental health

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved

OMB No. 3206 - 0250

To be given to the individual

examined with a pre-addressed

envelope marked

“Confidential - Medical”.

U.S. Office of Personnel Management

Section 3301 of Title 5 United States Code

Title 5 CFR 339

For Local Reproduction Only

Optional Form 178

July 2009

Formerly SF 78

Previous editions not useable

Page 7 of 8

Part C. CONTINUED - TO BE COMPLETED BY EXAMINING PHYSICIAN

5. Conclusions: Summarize below any medical findings that in your opinion, would limit this person's ability to perform these job duties or

make them a hazard to themselves or others. If none, so indicate.

No limiting conditions for this job

Limiting conditions as follows:

6. Examining Physician's Name7. E-Mail Address

8. Address (Including Street, City, State and ZIP Code) 9. Telephone Number

10. Signature of Examining Physician11. Date (Month, Day, Year)

IMPORTANT: After signing, return the entire form intact in the pre-addressed “Confidential-Medical” envelope which the person you

examined gave you.

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved

OMB No. 3206 - 0250

To be given to the individual

examined with a pre-addressed

envelope marked

“Confidential - Medical”.

U.S. Office of Personnel Management

Section 3301 of Title 5 United States Code

Title 5 CFR 339

For Local Reproduction Only

Optional Form 178

July 2009

Formerly SF 78

Previous editions not useable

Page 8 of 8

FOR AGENCY USE ONLY

Part D. TO BE COMPLETED BY AGENCY MEDICAL OFFICER (if one is available)

NOTE: Review the attached certificate of medical examination and make your recommendations in item 1 below.

1. Recommendation:

Hire or retain; describe limitations, if any, here.

Take action to separate or do not hire; explain why.

2. Agency Medical Officer's Name 3. E-Mail Address

4. Address (Including Street, City, State and ZIP Code) 5. Telephone Number

6. Signature of Agency Medical Officer7. Date (Month, Day, Year)

FOR AGENCY USE ONLY

Part E. TO BE COMPLETED BY AGENCY HUMAN RESOURCES OFFICER

1. Action Taken:

Hired or Retained

Non-Selected for Appointment, or Eligibility Objected To

Action Taken to Separate

2. Agency Human Resources Officer's Name3. E-Mail Address

4. Address (Including Street, City, State and ZIP Code) 5. Telephone Number

6. Signature of Agency Human Resources Officer7. Date (Month, Day, Year)