Attachment 3 - Optional Form 178 (Cert of Medical Exam).pdf

To be given to the individual examined with a pre-addressed envelope marked “Confidential - Medical”.

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved OMB No. 3206 - 0250

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only Applicant/ Employee:

Optional Form 178 December 2014 Formerly SF 78

Previous editions not useable Page 1 of 5

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), Employee Services, Recruitment and Hiring, Hiring 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.

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.

envelope marked “Confidential - Medical”.

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved OMB No. 3206 - 0250

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only Applicant/ Employee:

Optional Form 178 December 2014 Formerly SF 78

Previous editions not useable Page 2 of 5

Part A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE

1. Name (Last, First, Middle Initial)

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?

Yes No

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

6. Address (including City, State, Zip 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)

2. Social Security Number

7. E-mail Address 8. Telephone Numbers (with Area Code envelope marked “Confidential - Medical”.

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved OMB No. 3206 - 0250

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only Applicant/ Employee:

Optional Form 178 December 2014 Formerly SF 78

Previous editions not useable Page 3 of 5

Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

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

Pre-placement Other (Specify) Employment

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

See included Position Description.

Employment envelope marked “Confidential - Medical”.

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved OMB No. 3206 - 0250

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only Applicant/ Employee:

Optional Form 178 December 2014 Formerly SF 78

Previous editions not useable Page 4 of 5

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 Repeated bending ( .5 hours) Both eyes required

Moderate lifting, 15-44 pounds Climbing, legs only ( .5 hours) Depth perception

Light lifting, under 15 pounds Climbing, use of legs and arms Ability to distinguish basic colors

Heavy carrying, 45 pounds and over Both legs required Ability to distinguish shades of colors

Moderate carrying, 15-44 pounds Operation of crane, truck, tractor, or motor Hearing (aid permitted)

Light carrying, under 15 pounds vehicle Hearing without aid Straight pulling ( .5 hours) Ability for rapid mental and muscular Specific hearing requirements (specify) coordination simultaneously Pulling hand over hand ( .5 hours) Ability to use and desirability of using

Conversational Hearing

Pushing ( 2 hours) firearms Other (specify)

Reaching above shoulder Near vision correctable at 13” to 16” Mental and Emotional Stability

Use of fingers to Jaeger 1 to 4

Both hands required Far vision correctable in one eye to 20/20 and to 20/40 in the other

Walking ( 2 hours) Specific visual requirement (specify) Standing ( 2 hours)

Crawling ( hours) Kneeling ( .5 hours)

4b. Environmental Factors

Outside Electrical energy Working alone

Outside and inside Slippery or uneven walking surfaces Protracted or irregular hours of work

Excessive heat Working around machinery with moving parts Other (specify)

Excessive cold Working around moving objects or vehicles Contact with Body Fluids

Excessive humidity Working on ladders or scaffolding

Excessive dampness or chilling Working below ground

Dry atmospheric conditions Unusual fatigue factors (specify)

Excessive noise, intermittent

Constant noise Working with hands in water

Dust Explosives

Silica, asbestos, etc. Vibration

Fumes, smoke, or gases Working closely with others

Solvents (degreasing agents) Grease and oils

Radiant energy envelope marked “Confidential - Medical”.

CERTIFICATE OF MEDICAL EXAMINATION

U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved OMB No. 3206 - 0250

U.S. Office of Personnel Management Section 3301 of Title 5 United States Code Title 5 CFR 339 For Local Reproduction Only Applicant/ Employee:

Optional Form 178 December 2014 Formerly SF 78

Previous editions not useable Page 5 of 5

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 Name

4. Address (Including Street, City, State and ZIP Code) 5136 Eagle Drive USAF Academy, CO 80840

5. Telephone Number

(719) 333-3425

6. Signature of Agency Human Resources Officer 7. Date (Month, Day, Year)

X

Anne L. Hodges

3. E-Mail Address anne.hodges.2@us.af.mil mailto:anne.hodges.2@us.af.mil

MEMORANDUM In Lieu of OF-178 Part C/D

ATTN: NAF Human Resources Office Date:

SUBJECT: Certificate of Medical Examination Recommendations

Part C - 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

Part D - Review the attached certificate of medical examination and make your recommendations below.

Recommendation:

________Medically Qualified

________Medically Qualified - if restrictions accommodated (list restrictions):

________Medically Disqualified

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 Officer 7. Date (Month, Day, Year)

To be completed by Agency Medical Officer (if one is available) who reviews the examination results and recommends action. This memorandum serves as an interim in lieu of part C and D of the Optional Form (OF)

178. Review the attached certificate of medical examination and make your recommendations in item 1 below.-Upon completion of this form, an agency medical officer forwards this form to the agency human resources officer. A copy of the entire form, is retained in the medical record, in accordance with 5 Code

Federal Regulations 339.

Applicant Name: ______________________ Last 4 digits of SS: ______ PD#________

This document may contain information covered under the Privacy Act, 5 USC 552(a), and/or the Health Insurance Portability and

Accountability Act (PL 104-191) and its various implementing regulations and must be protected in accordance with those provisions.

Healthcare information is personal and sensitive and must be treated accordingly. If this correspondence contains healthcare information, it is being provided to you after appropriate authorization from the patient or under circumstances that do not require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure, and confidential manner. Disclosure without additional patient consent or as permitted by law is prohibited. Unauthorized disclosure or failure to maintain confidentiality subjects you to application of an appropriate sanction. If you have received this correspondence in error, please notify the sender at once and destroy any copies you have made.