WPC  77WPC >?>A ?k$ @E1?M]1?C"=8?YNT?M?(^= ?Oӆ?z9^=<,^o Z7>  (  (Untitled)'3,, , ,   UB ) 3    *    d +    d ,    d /0gjklmnopqrstuvwxyz{|}~P* * j:\inf41\y2kforms\jodysimi\sf78.wpf c:\inf41\phuong\sf78.wpfUS<&&&&&&  >?>f eh Terminal 1 ! d !  d      Terminal eb Arial " ! 2     d    Arial ev Times New Roman  ! 2 F  d    Times New Roman ed Symbol  ! ? !  d    Symbol ex Helvetica-Narrow " ! &     d    Helvetica-Narrow eb Roman  ! ?    d    Roman eh Helve-WP " ! ?     d     Helve-WP ej Wingdings  ! } F  d     Wingdings eX  ! K    d     eh MS Serif  ! ? !  d     MS Serif ed Modern 2 ! d    d    Modern ej Bodoni-WP  ! ? !  d     Bodoni-WP er MS Sans Serif " ! ? !  d    MS Sans Serif ed System " ! XS  d    System er CG Times (WN)  ! ? !  d    CG Times (WN) ef Courier 1 ! d !  d     Courier en Univers ATT " ! ? !  d     Univers ATT ep Times CG ATT  ! ? !  d     Times CG ATT ep Arial Narrow " ! &     d     Arial Narrow ?IAd A{?k$z jU c:\inf41\database\ SF78.DBFHISTORY   i%Name  5   h NAME5 i$SSN     h SSN i%Male      h MALE  i'Female      h FEMALE  i$DOB     h DOB i5Medical_Disorder_Yes      h  MEDICAL_D5  i4Medical_Disorder_No      h  MEDICAL_D6  i4Signature_Applicant  8   h  SIGNATURE78 i/Preappointment      h  PREAPPOIN8  i&Other      h OTHER  i3Other_Purpose_Exam     h  OTHER_PU10 i/Position_Title      h  POSITION11  i2Brief_Description      h  BRIEF_DE12  i,Hrs_Pulling     h  HRS_PULL13 i;Hrs_Pulling_Hand_Over_Hand     h  HRS_PULL14 i,Hrs_Pushing     h  HRS_PUSH15 i,Hrs_Walking     h  HRS_WALK16 i-Hrs_Standing     h  HRS_STAN17 i-Crawling_Hrs     h  CRAWLING18 i-Kneeling_Hrs     h  KNEELING19 i1Repeated_bending     h  REPEATED20 i*Legs_Only     h LEGS_ONLY i.Other_Specify      h  OTHER_SP22  i4Other_environmental      h  OTHER_EN23  i/Exam_Physician  ;   h  EXAM_PHY24; i)Address1  ;   h ADDRESS1; i)Address2  ;   h ADDRESS2; i*Signature  #   h SIGNATURE# i%Date     h DATE i'Height     h HEIGHT i%Feet     h FEET i'Weight     h WEIGHT i(Right20 !    h RIGHT20 i%Left "    h LEFT i.Glass_Right20 #    h  GLASS_RI34 i-Glass_Left20 $    h  GLASS_LE35 i/Without_GlassR %    h  WITHOUT_36 i5Without_Glass_R_into &    h  WITHOUT_37 i/Without_GlassL '    h  WITHOUT_38 i4Without_GlassL_into (    h  WITHOUT_39 i+WithglassR )    h  WITHGLASSR i0WithglassR_into *    h  WITHGLAS41 i+WithglassL +    h  WITHGLASSL i0WithglassL_into ,    h  WITHGLAS43 i1Color_Vision_Yes  -    h  COLOR_VI44  i0Color_Vision_No  .    h  COLOR_VI45  i/Other_Test_Yes  /    h  OTHER_TE46  i.Other_Test_No  0    h  OTHER_TE47  i*Right_Ear 1    h RIGHT_EAR i)Left_Ear 2    h LEFT_EAR i(T_1[A2] 3    h T_1_A2_  i(T_1[B2] 4    h T_1_B2_  i(T_1[C2] 5    h T_1_C2_  i(T_1[D2] 6    h T_1_D2_  i(T_1[E2] 7    h T_1_E2_ i(T_1[F2] 8    h T_1_F2_ i(T_1[G2] 9    h T_1_G2_ i(T_1[H2] :    h T_1_H2_ i(T_1[I2] ;    h T_1_I2_ i(T_1[J2] <    h T_1_J2_ i/Eyes_Ears_Nose  =    h  EYES_EAR60  i.Head_and_Back  >    h  HEAD_AND61  i'Speech  ?    h SPEECH  i5Skin_and_Lymph_nodes  @    h  SKIN_AND63  i(Abdomen  A    h ABDOMEN  i9Peripheral_blood_vessels  B    h  PERIPHER65  i,Extremities  C    h  EXTREMIT66  i&Sp_gr D    h SP_GR i(Albumen E    h ALBUMEN i&Sugar F    h SUGAR i&Casts G    h CASTS i&Blood H    h BLOOD i$Pus I    h PUS i2Respiratory_tract  J    h  RESPIRAT73  i&Heart  K    h HEART  i/Blood_pressure L    h  BLOOD_PR75 i&Pulse M    h PULSE i$EKG N K   h EKGK i-Explain_Back  O    h  EXPLAIN_78  i;Neurological_Mental_Health  P    h  NEUROLOG79  i)No_Limit  Q    h NO_LIMIT  i)Limiting  R    h LIMITING  i,Conclusions  S    h  CONCLUSI82  i(Name_P3 T 5   h NAME_P35 i'SSN_P3 U    h SSN_P3 i(Male_P3  V    h MALE_P3  i*Female_P3  W    h FEMALE_P3  i'DOB_P3 X    h DOB_P3 i4Med_Disorder_Yes_P3  Y    h  MED_DISO88  i3Med_Disorder_No_P3  Z    h  MED_DISO89  i2Applicant_Sign_P3 [ 9   h  APPLICAN909 i%Hire  \    h HIRE  i4Describe_Limitation  ]    h  DESCRIBE92  i,Take_Action  ^    h  TAKE_ACT93  i/Explain_Action  _    h  EXPLAIN_94  i3Agency_Medical_Ofc ` 5   h  AGENCY_M955 i/Location_Addr1 a .   h  LOCATION96. i/Location_Addr2 b .   h  LOCATION97. i0Date_Med_Agency c    h  DATE_MED98 i/Hired_Retained  d    h  HIRED_RE99  i6Action_Taken_Separate  e    h  ACTION_100  i-Non_Selected  f    h  NON_SEL101  i,Objected_To g A   h  OBJECTE102A i5Agency_Personnel_Ofc h 5   h  AGENCY_1035 i0Agency_Ofc_Sign i 5   h  AGENCY_1045 i0Agency_Ofc_Date j    h  AGENCY_105 i9Examining_Physician_Name k ;   h  EXAMINI106; i.Exam_Address1 l ;   h  EXAM_AD107; i.Exam_Address2 m ;   h  EXAM_AD108; i4Exam_Physician_Sign n #   h  EXAM_PH109# i4Exam_Physician_Date o    h  EXAM_PH110 ?@d @}?M V !        P      q& TO BE GIVEN TO PERSON  q& EXAMINED WITH A PRE-  q& ADDRESSED "CONFIDEN-  q& TIAL-MEDICAL" ENVELOPE.  !"#      n                       P  <&&&    !  &  UNITED STATES CIVIL SERVICE COMMISSION   2  CERTIFICATE OF MEDICAL EXAMINATION H !"#                             P  <&&     & & Form Approved  & Budget Bureau  & No. 50-R0073 E  !"#      Z                       P  <&&&    ! & Part A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE    (typewrite or print in ink) H !"#                             P  &&     V !@       P    ~<X }& 1. NAME (last, first, middle)< Name!"-./567 89: ;>?@ABCG                         P #      $      ' 5  Y@$.,! *  < <&&& = &&&    *fX q& 2. SOCIAL SECURITY ACCOUNT  q& NO.f SSN!"-./5&6789:;>?@ABCG                         P #      $      '  - -   Y@$.,! *  < <&& = &&&    m  q& 3. SEX 8  !"#                             P  <&&&     q& MALE   Male# $%:&'()+,-.                             P   !  *  1  2      3     Male=TRUE   Male           @RESETOBJ (Female)   Female    l q& FEMALE   Female# $%:& '()+,-.                             P   !  *  1  2      3     Female=TRUE   Female          @RESETOBJ (Male)   Male    TrxX q& 4. DATE OF BIRTHx DOB!"- ./5C67 89: ;>?@ABCG                         P #      $      '   Y@$.,! *  < <&&& = &&&    h4,  q& 5.   !"#                             P  <&&&    4B q& DO YOU HAVE ANY MEDICAL DISORDER OR PHYSICAL  q& IMPAIRMENT WHICH WOULD INTERFERE IN ANY WAY WITH  q& THE FULL PERFORMANCE OF THE DUTIES SHOWN BELOW?   !"#                             P  &&    n*4, q& 6. &  !"#                             P  <&&&     $4 q& I CERTIFY THAT ALL THE INFORMATION GIVEN BY ME IN CONNECTION WITH  q& THIS EXAMINATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND  q& BELIEF ( % !"#                             P  <&&      q& YES   Medical_Disorder_Yes#$%& '()+,-.                             P   !  *  1  2      3     +Medical_Disorder_Yes=TRUE +  Medical_Disorder_Yes          -@RESETOBJ (Medical_Disorder_No) ,  Medical_Disorder_No       q& NO   Medical_Disorder_No#$%& '()+,-.                             P   !  *  1  2      3     *Medical_Disorder_No=TRUE *  Medical_Disorder_No          .@RESETOBJ (Medical_Disorder_Yes) -  Medical_Disorder_Yes     < } (If your answer is "YES" explain fully to the physician performing the  } examination)    !"#      Z                       P  <&&&    k$( 6 } (signature of applicant)6 Signature_Applicant!"-./5(6 7"89:";>?@ABCG                         P #      $      ' 8  Y@$.,! *  < <&&& = &&&     ! &{ Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER H !"#                             P  &&     V  !       P     < q& 1. PURPOSE OF EXAMINATION   !"#                             P  <&&&    z  q& PREAPPOINTMENT   Preappointment #$%&' ()+,-.                             P   !  *  1  2      3     B }& OTHER (specify)   Other #$%&' ()+,-.                             P   !  *  1  2      3     <B.  Other_Purpose_Exam! "-./56789:;>?@ABCG                         P #      $      '   Y@$.,! *  < <&&& = &&&    ^* & q& 2. POSITION TITLE Position_Title! "-./5&67(89:(;>?@ABCG                         P #      $      '  A  Y@$.,! *  < <&&& = &&      !F q& 3. BRIEF DESCRIPTION OF WHAT POSITION REQUIRES EMPLOYEE TO DO! Brief_Description! "- ./567H89:H;>?@ABCG                         P #      $      '  v  Y@$.,! *  < <&&& = <&&    hP,# q& 4.  !"#                             P  <&&&    P!&$ } Circle the number preceding each functional requirement and each environmental factor 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. F !"#                             P  <&&    D!% & A. FUNCTIONAL REQUIREMENTS H !"#                             P  <&&&    pT ( }  1. Heavy lifting, 45 pounds and over  }  2. Moderate lifting, 15-44 pounds  }  3. Light lifting, under 15 pounds  }  4. Heavy carrying, 45 pounds and over  }  5. Moderate carrying, 15-44 pounds  }  6. Light carrying, under 15 pounds  }  7. Straight pulling (  }  8. Pulling hand over hand (  }  9. Pushing (  } 10. Reaching above shoulder  } 11. Use of fingers  } 12. Both hands required  } 13. Walking (  } 14. Standing (   !"#                             P  x&&&    J&~ } hours ) Hrs_Pulling!"-)./56"7 89:;>?@ABCG                         P #      $      '  !<6 !<6G$.,! *  < &&& =   &    Y` ~ } hours ) Hrs_Pulling_Hand_Over_Hand!"-*./56#7 89:;>?@ABCG                         P #      $      '  !<6 !<6G$.,! *  < &&& =   &    J@^~ } hours ) Hrs_Pushing!"-+./5 6$7 89:;>?@ABCG                         P #      $      '  !<6 !<6G$.,! *  < &&& =   &    Jr~ } hours ) Hrs_Walking!"-,./5 6'7 89:;>?@ABCG                         P #      $      '  !<6 !<6G$.,! *  < &&& =   &    ?t?CKr~~ } hours ) Hrs_Standing!"--./5 6(7 89:;>?@ABCG                         P #      $      '  !<6 !<6G$.,! *  < &&& =   &    l !. &u B. ENVIRONMENTAL FACTORS )H !"#                             P  <&&&    BpT / } 15. Crawling (  } 16. Kneeling (  } 17. Repeated bending (  } 18. Climbing, legs only (  } 19. Climbing, use of legs and arms  } 20. Both legs required  } 21. Operation of crane, truck, tractor, or motor  }  vehicle  } 22. Ability for rapid mental and muscular coor-  }  dination simultaneously  } 23. Ability to use and desirability of using  }  firearms  } 24. Near vision correctable at 13" to 16" to  }  Jaeger 1 to 4   !"#                             P  x&&&    Kp } hours )& Crawling_Hrs!"-0./5&6789:;>?@ABCG                         P #      $      '  !<6 !<6G$.,! *  < &&& = &&&    K8 } hours )& Kneeling_Hrs!"-1./5&6789:;>?@ABCG                         P #      $      '  !<6 !<6G$.,! *  < &&& =   &    O } hours )& Repeated_bending!"-2./5*6789:;>?@ABCG                         P #      $      '  !<6 !<6G$.,! *  < &&& =   &    pT 3 } 25. Far vision correctable in one eye to 20/20  }  and to 20/40 in the other  } 26. Far vision correctable in one eye to 20/50  }  and to 20/100 in the other  } 27. Specific visual requirement (specify)  } 28. Both eyes required  } 29. Depth perception  } 30. Ability to distinguish basic colors  } 31. Ability to distinguish shades of colors  } 32. Hearing (aid permitted)  } 33. Hearing without aid  } 34. Specific hearing requirements (specify)  } 35. Other (specify)  6  !"#                             P  x&&&    7(  Other_Specify!"-4./596(789:;>?@ABCG                         P #      $      '  #  Y@$.,!^ *  < <&&& = &&&    ."T 5 }  1. Outside  }  2. Outside and inside  }  3. Excessive heat  }  4. Excessive cold  }  5. Excessive humidity  }  6. Excessive dampness or chilling  }  7. Dry atmospheric conditions  }  8. Excessive noise, intermittent  }  9. Constant noise  } 10. Dust +  !"#                             P  x&&&    B."T 6 } 11. Silica, asbestos, etc.  } 12. Fumes, smoke, or gases  } 13. Solvents (degreasing agents)  } 14. Grease and oils  } 15. Radiant energy  } 16. Electrical energy  } 17. Slippery or uneven walking surfaces  } 18. Working around machinery with moving  }  parts  } 19. Working around moving objects or vehicles  +  !"#                             P  x&&&    ."T 7 } 20. Working on ladders or scaffolding  } 21. Working below ground  } 22. Unusual fatigue factors (specify)  } 23. Working with hands in water  } 24. Explosives  } 25. Vibration  } 26. Working closely with others  } 27. Working alone  } 28. Protracted or irregular hours of work  } 29. Other (specify) 6+  !"#                             P  x&&&    =((  Other_environmental!"-8./5964789:;>?@ABCG                         P #    Z  $    Z  '  #  Y@$.,!A *  < <&&& = &&     )!9 &~ Part C. TO BE COMPLETED BY EXAMINING PHYSICIAN 5H !"#                             P  &&     V b*! :      P    b*X }& 1. EXAMINING PHYSICIAN'S NAME (type or print) Exam_Physician!"-;./5667$89:$;>?@ABCG                         P #      $      ' ;  Y@$.,! *  < <&&& = &&&    ,X Address#$(?),-9.$/012456789                                    P ! "$%#&')*                    ;  Y@$.,!  ( &&& 3 <&&&    A     A     A     ?#     }& 2. ADDRESS (including ZIP Code)"<$%#&')*                     ;  Y@$.,!  ( <&&    5Address1"=$%#&')*                    ;  Y@$.,!  ( <&&    5Address2">$%#&')*                    ;  Y@$.,!  ( <&     b*@ q& 3. SIGNATURE OF EXAMINING PHYSICIAN *6$ !"#                             P  <&&&    T+(  } (signature)( Signature!"-A./5,68789:;>?@ABCG                         P #      $      ' #  Y@$.,! *  < <&& = &&&    L+~ }w (date)~ Date!"-B./5C687 89: ;>?@ABCG                         P #      $      ' #  Y@$.,! *  < <&& = &&&    2@HASVALUE (Date) and #UPDATONLY    Date  ~      7@datevalue (@datetext (Date, "%2-%1-%5"))   Date   %2-%1-%5  "  #  4@VALUE (@DATETEXT (Date,"%5"))<=29   Date   %5  "  x         o@SETVALUE (Date,@DATEVALUE (@CONCAT (@DATETEXT (Date,"%2-%1"),"-20",@DATETEXT (Date,"%5"))),TRUE)   Date   Date   %2-%1  "   -20   Date   %5  "      #       -C } IMPORTANT: After signing, return  the entire form intact in the pre-  } addressed "Confidential-Medical" envelope which the person you examined gave  } you. *9$ !"#      U                       P  xx    @/D d STANDARD FORM NO. 78  d OCTOBER 1969 (REVISION)  d CIVIL SERVICE COMMISSION  d FPM 339 B<  !"#                             P  &&&    r/ ^E &  78-110  < !"#                             P  &&&     0 d This form was electronically produced by Elite Federal Forms, Inc. =# !"#                             P  &&&    Hp } hours )& Legs_Only!"-./5*6 789:;>?@ABCG                         P #      $      '  !<6 !<6G$.,! *  < &&& =   &    ?=de =?YN V  &!- F      P    9 &!XG & N OTE   TO  E XAMINING  P HYSICIAN : The person you are about to examine will have to cope with the functional requirements and  & environmental factors circled on the other side of this form. Please take them, and the brief description of job duties above them, into  & consideration as you make your examination and report your findings and conclusions. H !"#                             P  xx&&     V  ~!^ H      P    [ F q& 1.  q& HEIGHT: Height!"-I./567 89:;>?@ABCG                         P #      $      '   Y@$.,! *  < <&& = &&&    Ef q& FEET, Feet!"-J./56789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& = &&&    m  K q& INCHES.  !"#                             P  &&&    IF q& WEIGHT:X Weight!"-L./5067 89:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& = &&&    m  N q& POUNDS. < !"#                             P  &&&    o O q& 2. EYES:  !"#                             P  <&&&    r Q & (A) Distant vision (Snellen): without glasses: right  !"#                             P  &&&    U,^ q&&  20, Right20!"-R./5"6789:;>?@ABCG                         P #      $      '   Y@$.,! *  < <&&& = &&&    jb~^T & left % !"#                             P  &&&&    R,^ q&&  20, Left!"-U./5'6789:;>?@ABCG                         P #      $      '   Y@$.,! *  < <&&& = &&&    ~V & ; with glasses, if worn: right ) !"#                             P  &&&&    [^^ q&X  20 Glass_Right20!"-W./586789:;>?@ABCG                         P #      $      '   Y@$.,! *  < <&&& = &&&    j~^X & left ; !"#                             P  &&&&    Z^ q&X  20 Glass_Left20!"-Y./5=6789:;>?@ABCG                         P #      $      '   Y@$.,! *  < <&&& = &&&    !Z & (B) 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.  F !"#                             P  &&&     [ } employees in the Federal classified service as may be requested  } by the Civil Service Commission or its authorized  } representative. This order will supplement the Executive Orders  } of May 29 and June 18, 1923 (Executive Order, September 4,  } 1924).   !"#      P                       P  xx     y\ }U Jaeger No. 2 Type    !"#                             P  <&&&     V   ! ]      P    L  q& R. Without_GlassR!"-_./5*6 789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& = &&&    V ` R q& in. to^ Without_Glass_R_into! "-`./516 789:;>?@ABCG                         P #      $      '    Y@$.,! *  < & & = &&&    L  q& L. Without_GlassL! "-a./5*6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& = &&&    U  R q& in. to^ Without_GlassL_into! "-b./516 789:;>?@ABCG                         P #      $      '    Y@$.,! *  < & & = &&&    xc } without glasses: )   !"#                             P  <&&&    HR  q& R. WithglassR! "-e./5<6 789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& = &&&    Q@` R q& in. to^ WithglassR_into! "-f./5B6 789:;>?@ABCG                         P #      $      '    Y@$.,! *  < & & = &&&    HR  q& L. WithglassL!"-g./5<6789:;>?@ABCG                         P #      $      '    Y@$.,! *  < &&& = &&&    Q@ R q& in. to^ WithglassL_into!"-h./5B6 789:;>?@ABCG                         P #      $      '    Y@$.,! *  < & & = &&&    ~i } with glasses, if used: ;  !"#                             P  <&&&    k^ ^j q& in. 8  !"#                             P  <&&    k^ ^k q& in. 8 !"#                             P  <&&    k" ^l q& in. I  !"#                             P  <&&    k" ^m q& in. I !"#                             P  <&&     n & (C) Color vision: Is color vision normal when Ishihara or other color plate test is used? . !"#                             P  &&    ,  &  YES   Color_Vision_Yes#p$%7&'()+,-.                             P   !  *  1  2      3     'Color_Vision_Yes=TRUE '  Color_Vision_Yes          )@RESETOBJ (Color_Vision_No) (  Color_Vision_No      &  NO   Color_Vision_No#q$%>&'()+,-.                             P   !  *  1  2      3     &Color_Vision_No=TRUE &  Color_Vision_No          *@RESETOBJ (Color_Vision_Yes) )  Color_Vision_Yes     ,s & If not, can applicant pass lantern, yarn, or other comparable test?  ( !"#                             P  &&    ??M  &  YES   Other_Test_Yes#t$%*&'()+,-.                             P   !  *  1  2      3     %Other_Test_Yes=TRUE %  Other_Test_Yes          '@RESETOBJ (Other_Test_No) &  Other_Test_No      &  NO   Other_Test_No#u$%0&'()+,-.                             P   !  *  1  2      3     $Other_Test_No=TRUE $  Other_Test_No          (@RESETOBJ (Other_Test_Yes) '  Other_Test_Yes       v & 3. EARS:   (Consider denominators indicated here as normal. Record as numerators the greatest distance heard.)  &  Ordinary conversation: C !"#                             P  <&    NnF q& RIGHT EAR Right_Ear!"-w./5 67 89:;>?@ABCG                         P #      $      '   Y@$.,! *  < <& = &&     V !x & 4. OTHER FINDINGS:  In items a through l briefly describe any abnormality (including diseases, scars, and disfigurations). Include brief  &  history, if pertinent. If normal, so indicate. H !"#                             P  <&    l6Xy q&j 20 ft.  !"#                             P  <&&&    N nF q& ; LEFT EAR Left_Ear!"-z./567 89:;>?@ABCG                         P #      $      '   Y@$.,! *  < <&& = &&     l 6X{ q&j 20 ft.  !"#                             P  <&&&    g<| q& .   !"#                             P  <&&    %BX & Audiometer (if given):  T_1#$(),+-./012456789                                    P ! h,"$%&')*                      Y@$.,!  ( &&& 3 &&&    A     A     ?h    ?h    ?h    ?h    ?h    ?h    ?h    ?h    ?h    ?h    @h q&/ 250"}$%&')*                       Y@$.,!  ( &&&    @h q&/ 500"~$%&')*                       Y@$.,!  ( &&&    Ah q& 1000"$%&')*                       Y@$.,!  ( &&&    Ah q& 2000"$%&')*                       Y@$.,!  ( &&&    Ah q& 3000"$%&')*                       Y@$.,!  ( &&&    Ah q& 4000"$%&')*                       Y@$.,!  ( &&&    Ah q& 5000"$%&')*                       Y@$.,!  ( &&&    Ah q& 6000"$%&')*                       Y@$.,!  ( &&&    Ah q& 7000"$%&')*                       Y@$.,!  ( &&&    Ah q& 8000 "$%&')*                       Y@$.,!  ( &&&    *h "$%&')*                      Y@$.,!  ( &&&    *h "$%&')*                      Y@$.,!  ( &&&    *h "$%&')*                      Y@$.,!  ( &&&    *h "$%&')*                      Y@$.,!  ( &&&    *h"$%&')*                      Y@$.,!  ( &&&    *h"$%&')*                      Y@$.,!  ( &&&    *h"$%&')*                      Y@$.,!  ( &&&    *h"$%&')*                      Y@$.,!  ( &&&    *h"$%&')*                      Y@$.,!  ( &&&    *h"$%&')*                      Y@$.,!  ( &&&     \X & a. Eyes, ears, nose, and throat (including tooth and oral hygiene) Eyes_Ears_Nose!"-./567#89:#;>?@ABCG                         P #      $      '  ;  Y@$.,!N *  <  = &&     X & b. Head and back (including face, hair, and scalp) Head_and_Back!"-./567#89:#;>?@ABCG                         P #      $      '  ;  Y@$.,!N *  < & = &&    l  X & c. Speech (note any malfunction) Speech!"-./567#89:#;>?@ABCG                         P #      $      '  ;  Y@$.,!N *  < & = &&     dX & d. Skin and lymph nodes (including thyroid gland) Skin_and_Lymph_nodes!"-./56 7#89:#;>?@ABCG                         P #      $      '  ;  Y@$.,!N *  < & = &&    P\X & e. Abdomen Abdomen!"-./5*67$89:$;>?@ABCG                         P #      $      '  ;  Y@$.,!N *  < & = &&    rX & f. Peripheral blood vessels Peripheral_blood_vessels!"-./5*67$89:$;>?@ABCG                         P #      $      '  ;  Y@$.,!N *  < & = &&    X X & g. Extremities Extremities!"-./5*67$89:$;>?@ABCG                         P #      $      '  ;  Y@$.,!N *  < & = &&    d & h. Urinalysis (if indicated) * $ !"#                             P  &&    HF & Sp. gr. Sp_gr!"-./5.6!7 89:;>?@ABCG                         P #      $      '    Y@$.,! *  < <&& = &&&    JF & Albumen Albumen!"-./5.6"7 89:;>?@ABCG                         P #      $      '    Y@$.,! *  < <&& = &&&    ?,?(F& & Sugar Sugar! "-./596!7 89:;>?@ABCG                         P #      $      '    Y@$.,! *  < <&& = &&&    F& & Casts Casts!!"-./596"7 89:;>?@ABCG                         P #      $      '    Y@$.,! *  < <&& = &&&    F & Blood Blood!""-./5C6!7 89:;>?@ABCG                         P #      $      '    Y@$.,! *  < <&& = &&&    B & Pus Pus!#"-./5C6"7 89:;>?@ABCG                         P #      $      '    Y@$.,! *  < <&& = &&&     !  & i. Respiratory tract (X-ray if indicated)! Respiratory_tract!$"-./56#7H89:H;>?@ABCG                         P #      $      '  ;  Y@$.,!N *  < & = &&      & j. Heart (size, rate, rhythm, function) '# !"#                             P  &&    Xd & Blood pressure Blood_pressure!&"-./5 6(789:;>?@ABCG                         P #      $      '   Y@$.,! *  < &&& = &&&    Fdl  & Pulse Pulse!'"-./5 6)7 89:;>?@ABCG                         P #      $      '   Y@$.,! *  < && = &&&    Wd4!  & EKG (if indicated) EKG!("-./5 6*7D89: ;>?@ABCG                         P #      $      ' K  Y@$.,! *  < &&& = &&&     !!X & k. Back (special consideration for positions involving heavy lifting and other strenuous duties)! Explain_Back!)"-./56+7H89:H;>?@ABCG                         P #      $      '  ;  Y@$.,!N *  < & = &&    z T$!  & l. Neurological and mental health! Neurological_Mental_Health!*"-./56.7H89:H;>?@ABCG                         P #      $      '  ;  Y@$.,!N *  < & = &&    B t'! & CONCLUSIONS: Summarize below any medical findings which, in your opinion, would limit this person's performance of the job duties  & and/or would make him a hazard to himself or others. If none, so indicate. 2H !"#      U                       P  &&     ~(f q& No limiting conditions for this job   No_Limit+#$% &4'()+,-.                             P   !  *  1  2      3     No_Limit=TRUE   No_Limit          "@RESETOBJ (Limiting) !  Limiting    ~h)f q& Limiting conditions as follows:   Limiting,#$% &5'()+,-.                             P   !  *  1  2      3     Limiting=TRUE   Limiting          "@RESETOBJ (No_Limit) !  No_Limit    5 0*! Conclusions!-"-./5667H89:;>?@ABCG                         P #      $      '  u  Y@$.,! *  < <&&& = &&    /  Heart!%"-./56'7289:;>?@ABCG                         P #      $      '  R  Y@$.,!4 *  < <&&& = &&&    ?7= d e f =l?O! & Part A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE    (typewrite or print in ink) H !"#                             P  &&     V !       P    w<X }& 1. NAME (last, first, middle)< Name_P3!"-./567 89: ;>?@ABCG                         P #      $      ' 5  Y@$.,! *  < <&&& = &&&    Name   Name  *fX q& 2. SOCIAL SECURITY ACCOUNT  q& NO.f SSN_P3!"-./5&6789:;>?@ABCG                         P #      $      '  - -   Y@$.,! *  < <&&& = &&&    SSN   SSN  s q& 3. SEX 8  !"#                             P  <&&    r q& MALE    Male_P3#$%:&'()+,-.                             P   !  *  1  2      3     Male   Male  : q& FEMALE    Female_P3#$%:& '()+,-.                             P   !  *  1  2      3     Female   Female  Y@X q& 4. DATE OF BIRTH DOB_P3!"-./5B67 89: ;>?@ABCG                         P #      $      '   Y@$.,! *  < <&&& = &&&    DOB   DOB  h4X q& 5.   !"#                             P  <&&    4BX q& DO NOT HAVE ANY MEDICAL DISORDER OR PHYSICAL  q& IMPAIRMENT WHICH WOULD INTERFERE IN ANY WAY WITH  q& THE FULL PERFORMANCE OF THE DUTIES SHOWN BELOW?   !"#                             P  &&    l  q& YES    Med_Disorder_Yes_P3#$%& '()+,-.                             P   !  *  1  2      3     "Medical_Disorder_Yes +  Medical_Disorder_Yes     q& NO    Med_Disorder_No_P3#$%& '()+,-.                             P   !  *  1  2      3     !Medical_Disorder_No *  Medical_Disorder_No   < } (If your answer is "YES" explain fully to the physician performing the  } examination)    !"#                             P  <&&&    h*4X q& 6. &  !"#                             P  <&&     $4X q& I CERTIFY THAT ALL THE INFORMATION GIVEN BY ME IN CONNECTION WITH  q& THIS EXAMINATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND  q& BELIEF ( % !"#                             P  <&    k$ h } (signature of applicant)h Applicant_Sign_P3!"-./5(6 7#89:#;>?@ABCG                         P #      $      ' 9  Y@$.,! *  < &&& = &&&    !Signature_Applicant *  Signature_Applicant   ! & Part D. TO BE COMPLETED BY AGENCY MEDICAL OFFICER    (if one is available) H !"#                             P  &&&&     ! & N OTE:  Review the attached certificate of medical examination and make your recommendations in item 1 below. If the medical examination  & was done for pre-appointment purposes, circle the appropriate handicap code in Part F. H !"#      Z                       P  &&&     V !        P    y q& 1. RECOMMENDATION:   !"#                             P  <&&&    ,n d HIRE OR RETAIN, DESCRIBE LIMITATIONS, IF ANY, HERE.   Hire #$%&'()+,-.                             P   !  *  1  2      3     =6 Describe_Limitation! "-./5 67A89:;>?@ABCG                         P #      $      '  n  Y@$.,!L *  < <&&& = H&&    5$< d TAKE ACTION TO SEPARATE OR DO NOT HIRE. EXPLAIN WHY.   Take_Action #$%&' ()+,-.                             P   !  *  1  2      3     >X Explain_Action! "-./5 67A89:;>?@ABCG                         P #      $      '  n  Y@$.,!L *  < <&&& = H&&    D<X & 2. AGENCY MEDICAL OFFICER'S NAME   (type or print)< Agency_Medical_Ofc! "-./567 89: ;>?@ABCG                         P #      $      ' 5  Y@$.,! *  < <& = &&&    *D X Location#$(),&-./012456789                                    P ! H "$%&')*                    .  Y@$.,!  ( &&& 3 <&&&    A     A     A     ?     r  }& 3. LOCATION (City, State, ZIP Code)"$%&')*                     .  Y@$.,!  ( <&    9 Location_Addr1"$%&')*                    .  Y@$.,!  ( <&&    9 Location_Addr2"$%&')*                    .  Y@$.,!  ( <&&    W@DX q& 4. DATE Date_Med_Agency!"-./5B67 89: ;>?@ABCG                         P #      $      '   Y@$.,! *  < <&&& = &&&    =@HASVALUE (Date_Med_Agency) and #UPDATONLY  &  Date_Med_Agency  ~      B@datevalue (@datetext (Date_Med_Agency, "%2-%1-%5")) &  Date_Med_Agency   %2-%1-%5  "  #  ?@VALUE (@DATETEXT (Date_Med_Agency,"%5"))<=29 &  Date_Med_Agency   %5  "  x         @SETVALUE (Date_Med_Agency,@DATEVALUE (@CONCAT (@DATETEXT (Date_Med_Agency,"%2-%1"),"-20",@DATETEXT (Date_Med_Agency,"%5"))),TRUE) (  Date_Med_Agency &  Date_Med_Agency   %2-%1  "   -20 &  Date_Med_Agency   %5  "      #       ! &r Part E. TO BE COMPLETED BY AGENCY PERSONNEL OFFICER  H !"#                             P  <&&&    &d#  & N OTE:  Enter the action taken below. If this form is used for pre-appointment purposes, be sure the appropriate handicap code in Part F is circled.  &  IMPORTANT: See FPM Chapter 293, Subchapter 3; FPM Chapter 339; and FPM Supplement 339-31 for disposition and/or filing of both  &  parts of this form, either separately or together.  L !"#      Z                       P  &&&     V !       P    wF q& 1. ACTION TAKEN: $  !"#                             P  <&&    L@ d HIRED OR RETAINED.   Hired_Retained#$%&%' ()+,-.                             P   !  *  1  2      3     #f d ACTION TAKEN TO SEPARATE.   Action_Taken_Separate#$%&&'()+,-.                             P   !  *  1  2      3     ?,?z9: L d NON-SELECTED FOR APPOINTMENT, OR ELIGIBILITY OBJECTED TO.   Non_Selected#$%&%'#()+,-.                             P   !  *  1  2      3     5z  Objected_To!"-./56&7(89:;>?@ABCG                         P #      $      ' A  Y@$.,! *  < <&&& = &&&    <X }& 2. AGENCY PERSONNEL OFFICER'S NAME (type or print)< Agency_Personnel_Ofc!"-./56'7 89: ;>?@ABCG                         P #      $      ' 5  Y@$.,! *  < <& = &&&    Z* X q& 3. SIGNATURE Agency_Ofc_Sign!"-./5&6'789:;>?@ABCG                         P #      $      ' 5  Y@$.,! *  < <& = &&&    W@X q& 4. DATE Agency_Ofc_Date!"-./5B6'7 89: ;>?@ABCG                         P #      $      '   Y@$.,! *  < <& = &&&    =@HASVALUE (Agency_Ofc_Date) and #UPDATONLY  &  Agency_Ofc_Date  ~      B@datevalue (@datetext (Agency_Ofc_Date, "%2-%1-%5")) &  Agency_Ofc_Date   %2-%1-%5  "  #  ?@VALUE (@DATETEXT (Agency_Ofc_Date,"%5"))<=29 &  Agency_Ofc_Date   %5  "  x         @SETVALUE (Agency_Ofc_Date,@DATEVALUE (@CONCAT (@DATETEXT (Agency_Ofc_Date,"%2-%1"),"-20",@DATETEXT (Agency_Ofc_Date,"%5"))),TRUE) (  Agency_Ofc_Date &  Agency_Ofc_Date   %2-%1  "   -20 &  Agency_Ofc_Date   %5  "      #       4!! & Part F. HANDICAP CODE    (to be completed only in pre-appointment cases) *H !"#                             P  <&     V !!H        P    k!! &* If the person examined has or had a handicap listed below, circle the code number which pertains to that handicap. If more than one handicap  & applies, circle the one considered most limiting. If none of the handicap codes apply, circle code "00". +H !"#      Z                       P  <&&&    #T @ } 00 No handicap of the type listed  } 10 Amputation--one major extremity  } 11 Amputation--two or more major extremities  } 20 Deformity or impaired function--upper  }  extremity  } 21 Deformity or impaired function--lower  }  extremity or back  } 30 Vision--one eye only  } 31 No usable vision . !"#                             P  x& &    B#T @ } 40 Hearing aid required  } 41 No usable hearing  } 42 No usable hearing, with speech malfunction  } 43 Normal hearing, with speech malfunction  } 50 Tuberculosis--inactive pulmonary  } 51 Organic heart disease (compensated)--val-  }  vular, arrhythmia, arteriosclerosis, healed  }  coronary lesions . !"#                             P  x& &    v#T @ } 52 Diabetes--controlled  } 53 Epilepsy--adequately controlled  } 54 History of emotional behavioral problems  }  requiring special placement effort  } 55 Mentally retarded  } 56 Mentally restored 6. !"#                             P  x& &    *X }& 1. EXAMINING PHYSICIAN'S NAME (type or print) Examining_Physician_Name!"-./5667$89:$;>?@ABCG                         P #      $      ' ;  Y@$.,! *  < <& = &&&    Exam_Physician %  Exam_Physician  ,X Exam_Address#$(),-9.$/012456789                                    P ! "$%#&')*                    ;  Y@$.,!  ( &&& 3 <&&&    A     A     A     ?#     }& 2. ADDRESS (including ZIP Code)"$%#&')*                     ;  Y@$.,!  ( <&    <Exam_Address1"$%#&')*                    ;  Y@$.,!  ( <&&    Address1 ) AddressAddress1  <Exam_Address2"$%#&')*                    ;  Y@$.,!  ( <&&    Address2 ) AddressAddress2  * q& 3. SIGNATURE OF EXAMINING PHYSICIAN *6$ !"#                             P  <&&&    `$,(  } (signature)( Exam_Physician_Sign!"-./5,68789:;>?@ABCG                         P #      $      ' #  Y@$.,! *  < <&& = &&&    Signature    Signature  ]$,~ }w (date)~ Exam_Physician_Date!"-./5C687 89: ;>?@ABCG                         P #      $      ' #  Y@$.,! *  < <&& = &&&    A@HASVALUE (Exam_Physician_Date) and #UPDATONLY  *  Exam_Physician_Date  ~      date   Date  C@VALUE (@DATETEXT (Exam_Physician_Date,"%5"))<=29 *  Exam_Physician_Date   %5  "  x         @SETVALUE (Exam_Physician_Date,@DATEVALUE (@CONCAT (@DATETEXT (Exam_Physician_Date,"%2-%1"),"-20",@DATETEXT (Exam_Physician_Date,"%5"))),TRUE) ,  Exam_Physician_Date *  Exam_Physician_Date   %2-%1  "   -20 *  Exam_Physician_Date   %5  "      #       P- } IMPORTANT: After signing, return  the entire form intact in the pre-  } addressed "Confidential-Medical" envelope which the person you examined gave  } you. *:$ !"#      Z                       P  xx    y! & FOR AGENCY USE ONLY H !"#                             P  <&&&    ?\=d e =<,defgh i <^o elite10.DLL IVALID FILLER This form was Designed by Elite Federal Forms and requires the Elite/Novell Filler! Call 410-647-9691 for more information. elite10.COM IVALID FILLER This form was Designed by Elite Federal Forms and requires the Elite/Novell Filler! Call 410-647-9691 for more information. WPIN$ELITE10FunctionSet,4.1 ^=ZeZ