attmt__6_Employee_Medical_Examination_Rating_Sheet_Template.pdf

PDF 26 KB Posted Oct 28, 2013

Attached to: Pre-employment and Employee Medical Services
Solicitation number: HSBP1013R0033
Issued by: Department of Homeland Security Customs and Border Protection

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Attachment 6 Employee Medical Examination Rating Sheet

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CBP EMPLOYEE MEDICAL EXAMINATION REVIEW FORM

EXAMINEE NAME: ____________________________________________________

LAST FOUR NUMBERS OF EXAMINEE’S SSN: _____________________________

EXAMINATION DATE:___________________________________________________

POSITION: ____________________________________________________________

REVIEWING PHYSICIAN COMMENTS:

____Examination does not reveal a medical condition which explains the mental health issue raised; recommend proceeding with psychiatric IME

____Recommend the following type of IME:______________________________________

Other recommendation:____________________________________________________________________

Physician’s Printed Name: Date:

Signature:___________________________________________________________________

File details come from the government source that posted it. Updated Nov 14, 2017.