SF_78_Fillable.xlsx
XLSX spreadsheet 75 KB Posted
- Attached to
- Medical Examination Services - Grissom ARB, IN
- Solicitation number
- FA4654-14-B-0001
About this file
Certificate of Medical Examination - Standard Form 78
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Other files
| File | Type | Posted |
|---|---|---|
| GRISSOM_PWS_FOR_FA4654-14-B-0001_3_MAR_2014.pdf | ||
| NFPA_1582_2007_Edition_TIG.pdf | ||
| AF_Form_2755.doc | DOC document | |
| AF_Form_2766_Example.docx | DOCX document | |
| FA4654-14-B-0001_Medical_Services_Grissom_ARB _IN_31_Jan_2014.pdf | ||
| SF_600.pdf | ||
| AF_PD.pdf | ||
| Respirator_Initial_Questionnaire.doc | DOC document | |
| afi31-122_(PAT).pdf | ||
| Respirator_Annual_Questionnaire.doc | DOC document |
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Text version
TO BE GIVEN TO PERSON EXAMINED WITH A PRE-ADDRESSED CONFIDENTIAL MEDICAL” ENVELOPE. UNITED STATES CIVIL SERVICE COMMISSION
CERTIFICATE OF MEDICAL EXAMINATION
| Form Approved Budget Bureau No. 50—R0073 | |||||
| Part A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE (typewrite or print in ink) | |||||
| 1. NAME (last, first, middle) | 2. SOCIAL SECURITY ACCOUNT NO. | 3. SEX | 4. DATE OF BIRTH |
| 5. DO YOU HAVE ANY MEDICAL DISORDER OR PHYSICAL | 6. I CERTIFY THAT ALL THE INFORMATION GIVEN BY ME IN CONNECTION |
| IMPAIRMENT WHICH WOULD INTERFERE IN ANY WAY WITH THE | WITH THIS EXAMINATION IS CORRECT TO THE BEST OF MY KNOWLEDGE |
| FULL PERFORMANCE OF THE DUTIES SHOWN BELOW? | AND BELIEF. |
| (If your answer is YES' explain fully to the physician performing the examination) | ___________________________________________________ |
(signature of applicant)
| Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER | |
| 1. PURPOSE PF EXAMINATION | 2. POSITION TITLE |
3. BRIEF DESCRIPTION OF WHAT POSITION REQUIRES EMPLOYEE TO DO
| 4. Checkmark the box 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. | |||
| A. FUNCTIONAL REQUIREMENTS | |||
| 1. Heavy lifting, 50 pounds and over | 15. Crawling (hours) | 27. Specific visual requirement (specify) | |
| 2. Moderate lifting, 15-44 pounds | 16. Kneeling (hours) | ||
| 3. Light lifting, under 15 pounds | 17. Repeated bending (hours) | 28. Both eyes required | |
| 4. Heavy carrying 50 pounds and over | 18. Climbing, legs only (hours) | 29. Depth perception | |
| 5. Moderate carrying, 15-44 pounds | 19. Climbing, use of legs and arms | 30. Ability to distinguish basic colors | |
| 6. Light carrying, under 15 pounds | 20. Both legs required | 31. Ability to distinguish shades of colors | |
| 7. Straight pulling ( hours) | 21. Operation of crane, truck, tractor, or motor vehicle | 32. Hearing (aid permitted) | |
| 8. Pulling hand over hand ( hours ) | 22. Ability for rapid mental and muscular coordination simultaneously | 33. Hearing without aid | |
| 9. Pushing (hours) | 23. Ability to use and desirability of using firearms | 34. Specific hearing requirements (specify) | |
| 10. Reaching above shoulder | 24. Near vision correctable at 13” to 16” to Jaeger 1 to 4 | ||
| 11. Use of fingers | 25. Far vision correctable in one eye to 20/20 and to 20/40 in the other | 35. Other (specify) | |
| 12. Both hands required | 26. Far vision correctable in one eye to 20/50 and to 20/100 in the other | ||
| 13. Walking (hours) | |||
| 14. Standing (hours) | |||
| B. ENVIRONMENTAL FACTORS | |||
| 1. Outside | 11. Silica, asbestos, etc. | 21. Working below ground | |
| 2. Outside and inside | 12. Fumes, smoke, or gases | 22. Unusual fatigue factors (specify) | |
| 3. Excessive heat | 13. Solvents (degreasing agents) | 23. Working with hands in water | |
| 4. Excessive cold | 14. Grease and oil | 24. Explosives | |
| 5. Excessive humidity | 15. Radiant energy | 25. Vibration | |
| 6. Excessive dampness or chilling | 16. Electrical energy | 26. Working closely with others | |
| 7. Dry atmospheric conditions | 17. Slippery or uneven walking surfaces | 27. Working alone | |
| 8. Excessive noise, intermittent | 18. Working around machinery with moving parts | 28. Protracted or irregular hours of work | |
| 9. Constant Noise | 19. Working around moving objects or vehicles | 29. Other (specify) | |
| 10. Dust | 20. Working on ladders or scaffolding | ||
| C. TO BE COMPLETED BY EXAMINING PHYSICIAN | |||
| 1. EXAMINING PHYSICIAN'S NAME (type or print) | 3. SIGNATURE OF EXAMINING PHYSICIAN |
| 2. ADDRESS (INCLUDING ZIP CODE) | (SIGNATURE) | (DATE) |
| IMPORTANT: After signing, return the entire form intact in the preaddressed “Confidential | ||
| Medical” envelope which the person you examined gave you. |
STANDARD FORM NO. 78
| 78-110 | OCTOBER 1969 (REVISION) |
| CIVIL SERVICE COMMISSION |
FPM 339
Supervisors Signature Date
MALE
FEMALE
YES
NO
PREAPPOINTMENT
OTHER (SPECIFY)
NOTE TO EXAMINING PHYSICIAN: 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 these, and the brief description of the job duties above them, 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 glasses: | right | left | ; with glasses, if worn; | right | left | ||||||
| (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 | |||||||||||
| Without glasses: | With glasses, if used: | ||||||||||
| L | in. to | in. | L | in. to | in. | ||||||
| R | in. to | in. | R | in. to | in. |
| (C) Color vision: Is color vision normal when Ishihara or other color plate test is used? | ||||||||||||||
| If not, can applicant pass lantern, yarn, or other comparable test? | ||||||||||||||
| 3. EARS: (Consider denominators indicated here as normal. Record as numerators the greatest distance heard.) | ||||||||||||||
| 250 | 500 | 1000 | 2000 | 3000 | 4000 | 5000 | 6000 | 7000 | 8000 | |||||
| Ordinary Conversation | Audiometer (if given): | |||||||||||||
| RIGHT EAR | LEFT EAR | |||||||||||||
| 20FT | 20FT | |||||||||||||
| 4. OTHER FINDINGS: In items a through I briefly describe any abnormality (including diseases, scars, and disfigurations). Include brief history, if pertinent. If normal, so indicate. | ||||||||||||||
| a. Eyes, ears, nose, and throat (including tooth and oral hygiene) | e. Abdomen |
b. Head and back (including face, hair, and scalp) f. Peripheral blood vessels
c. Speech (note any malfunction) g. Extremities
| d. 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)
I. Neurological and Mental Health
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.
Jaeger No. 2 Type Employees in the Federal classified service as may be required 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)
YES
NO
YES
NO
No limiting conditions for this job Limiting conditions as follows:
FOR AGENCY USE ONLY
| Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER | |||
| 1. NAME (last, first, middle) | 2. SOCIAL SECURITY ACCOUNT NO. | 3. SEX | 4. DATE OF BIRTH |
| 5. DO YOU HAVE ANY MEDICAL DISORDER OR PHYSICAL IMPAIRMENT WHICH WOULD INTERFERE IN ANY WAY WITH THE FULL PERFORMANCE OF THE DUTIES SHOWN BELOW? | 6. I CERTIFY THAT ALL THE INFORMATION GIVEN BY ME IN CONNECTION WITH THIS EXAMINATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. | |
| (If your answer is YES' explain fully to the physician performing the examination) | (signature of applicant) | |
| 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. If the medical examination was done for pre-appointment purposes, circle the appropriate handicap code in part F. | ||
| 1. RECOMMENDATION: |
2. AGENCY MEDICAL OFFICER'S NAME (type or print) 3. LOCATION (city, state, ZIP code) 4. DATE
| Part E. TO BE COMPLETED BY AGENCY PERSONNEL OFFICER | |||||
| NOTE: 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. | |||||
| 1. ACTION TAKEN: | |||||
| 2. AGENCY PERSONNEL OFFICER'S NAME (Type or print) | 3. SIGNATURE | 4. DATE | |||
| Tammy Schlarf | |||||
| Part F. HANDICAP CODE (to be completed only in pre-appointment cases) | |||||
| 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". | |||||
| 00 No handicap of the type listed | 40 Hearing aid required | 52 Diabetes-controlled | |||
| 10 Amputations-one major extremity | 41 No usable hearing | 53 Epilepsy-adequately controlled | |||
| 11 Amputation-two or more major extremities | 42 No usable hearing, with speech malfunction | 54 History of emotional behavioral problems requiring special placement effort | |||
| 20 Deformity or impaired function-upper extremity | 43 Normal hearing, with speech malfunction | ||||
| 21 Deformity or impaired function-lower extremity or back | 44 Tuberculosis-inactive pulmonary | 55 Mentally retarded | |||
| 30 Vision-one eye only | 45 Organic heart disease (compensated)-Valvular, arrhythmia, arteriosclerosis, healed coronary lesions | 56 Mentally restored | |||
| 31 No usable vision | |||||
| 1. EXAMINING PHYSICIAN’S NAME (type or print) | 3. I CERTIFY THAT ALL THE INFORMATION GIVEN BY ME IN CONNECTION WITH THIS EXAMINATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. |
| 2. ADDRESS (including ZIP Code) | |
| (signature of applicant) |
TAKE ACTION TO SEPARATE OR DO NOT HIRE, EXPLAIN WHY.
HIRE OR RETAIN DESCRIBE LIMITATIONS, IF ANY, HERE:
Male Female Yes No Hired or Retained Non-Selected for Appointment, or Eligibility Objected To Action Taken to Separate
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