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Fillable Printable OF 178

Fillable Printable OF 178

OF 178

OF 178

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
YesNo
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)
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