Attmt 11 - Candidate Medical Examination Rating Sheet Template.pdf
PDF 624 KB Posted
- Solicitation number
- 70B06C26R00000017
About this file
This is a U.S. Customs and Border Protection (CBP) Candidate Medical Examination and Rating form used to document a physician's evaluation of an individual's medical fitness for a selected position.
The form requires the Primary Reviewing Physician to document their review of the candidate's medical records, including history, physical examination findings, audiogram, secondary audiogram (if applicable), vision assessment, secondary vision assessment (if applicable), and any other relevant medical information. The physician must then indicate one of two conclusions: either the individual is medically qualified for the position indicated, or the individual is not medically qualified. If the candidate is deemed medically unqualified, the physician must identify specific medical information that should be considered to determine the candidate's current health status and stability of identified conditions, such as complete medical records, clinical findings from recent examinations, laboratory results, x-rays, EKGs, and other diagnostic procedures. The form includes fields for candidate identification (last name, first name, middle name, SSN, and selected position), Primary Reviewing Physician printed name and signature, and date of review. This template is designed to standardize medical clearance determinations for CBP employment candidates.
View the file
Other files
Show all 42
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
I have reviewed the:
- History
- Physical
- Audiogram
- Secondary Audiogram (if applicable)
- Vision
- Secondary Vision (if applicable)
- Other: __________________________
THE INDIVIDUAL IS MEDICALLY QUALIFIED FOR THE POSITION INDICATED
Primary Reviewing Physician Signature Date
The information obtained from the physical examination does not demonstrate the individual meets the medical standards for the position. To determine the individual’s current health status and the stability of the condition(s) identified, the following information should be considered (e.g., complete copy of medical records, clinical findings from a recent medical examination, results/reports from specific laboratory tests, x-rays, EKGs, other special evaluations or diagnostic procedures, etc.)
Primary Reviewing Physician Date dfi4ivu Typewritten Text dfi4ivu Typewritten Text dfi4ivu Typewritten Text dfi4ivu Typewritten Text dfi4ivu Typewritten Text dfi4ivu Typewritten Text dfi4if8 Typewritten Text dfi4if8 Typewritten Text Last Name First Name Middle Name dfi4if8 Typewritten Text dfi4if8 Typewritten Text Candidate SSN dfi4if8 Typewritten Text Selected Position dfi4if8 Typewritten Text dfi4if8 Typewritten Text dfi4if8 Typewritten Text dfi4if8 Line dgfn330 Typewritten Text dgfn330 Typewritten Text dgfn330 Typewritten Text dgfn330 Typewritten Text dgfn330 Typewritten Text dgfn330 Text Box Primary Reviewing Physician Printed Name
| SELECTED POSITION: |
| MEDICAL ID: |
| Primary Reviewing Contract Physician Signature: |
| Additional records reviewed: |
| Title: U.S. Customs and Border Protection |
Candidate Medical Examination and Rating
| Text6: THE INDIVIDUAL IS NOT MEDICALLY QUALIFIED FOR THE POSITION INDICATED |
| Check Box1: Off |
| Check Box2: Off |
| LAST NAME, FIRST NAME MIDDLE NAME: |
| Date MM/DD/YYYY: |
File details come from the government source that posted it. Updated .