attmt__5_Candidate_Medical_Examination_Rating_Sheet_Template.pdf

I have reviewed the:

- History

- Physical

- Audiogram

- Resting EKG

- Vision

- PPD Mantoux Test

- 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 CBP Medical ID 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

Candidate Medical Examination and Rating