Attachment 21d SF78 Certificate of Medical Examination.pdf

78-110

Part A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE (typewrite or print in ink)

1. SOCIAL SECURITY ACCOUNT NO. SEX DATE OF BIRTH

DO YOU HAVE ANY MEDICAL DISCORDER OR PHYSICAL

(Signature of applicant)

Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

PURPOSE OF EXAMINATION POSITION TITLE

BRIEF DESCRIPTION OF WHAT POSITION REQUIRES EMPLOYEE TO DO

A. FUNCTIONAL REQUIREMENTS

B. ENVIRONMENTAL FACTORS

Part C. TO BE COMPLETED BY EXAMINING PHYSICIAN EXAMINING PHYSICIAN'S NAME (Type or print) SIGNATURE OF EXAMINING PHYSICIAN

ADDRESS (Including ZIP Code) (Signature) (Date)

TO BE GIVEN TO PERSON

EXAMINED WITH A PRE-

ADDRESSED "CONFIDEN-

TIAL-MEDICAL" ENVELOPE.

UNITED STATES CIVIL SERVICE COMMISSION

CERTIFICATE OF MEDICAL EXAMINATION

Form Approved Budget Bureau No. 50-R0073

NAME (last, first, middle) 2. 3.

MALE

FEMALE

4.

5.

IMPAIRMENT WHICH WOULD INTERFERE IN ANY WAY WITH

THE FULL PERFORMANCE OF THE DUTIES SHOWN BELOW?

YES NO

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

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.

1.

PREAPPOINTMENT

OTHER (Specify)

2.

3.

4. Circle the number 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, attached the specific medical standards for the information of the examining physician.

1.

2.

3.

IMPORTANT: After signing, return the entire form intact in the pre-addressed "Confidential-Medical" envelope which the person you exam-ined gave you.

STANDARD FORM NO. 78

OCTOBER 1969 (REVISION)

CIVIL SERVICE COMMISSION

FPM 239

Heavy lifting, 45 pounds and over Moderate lifting, 15-44 pounds Light lifting, under 15 pounds Heavy carrying, 45 pounds and over Moderate carrying, 15-44 pounds Light carrying, 15-44 pounds Straight pulling ( hours) Pulling hand over hand ( hours) Pushing ( hours) Reaching above shoulder Use of fingers Both hands required Walking ( Standing ( hours) hours)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

Crawling (

Repeated bending ( Kneeling (

Jaeger 1 to 4

Climbing, legs only ( Climbing, use of legs and arms Both legs required Operation of crane, truck, tractor, or motor vehicle Ability for rapid mental and muscular coor-dination simultaneously Ability to use and desirability of using firearms Near vision correctable at 13" to 16" to hours) hours) hours) hours)

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

Far vision correctable in one eye to 20/20 and to 20/40 in the other Far vision correctable in one eye to 20/50 and to 20/100 in the other

Both eyes required Specific visual requirement (specify)

Depth perception Ability to distinguish basic colors Ability to distinguish shades of colors

Hearing without aid Hearing (aid permitted)

Specif hearing requirements (specify) Other (specify)

Outside Outside and inside Excessive heat Excessive cold Excessive humidity Excessive dampness or chilling Dry atmospheric conditions Excessive noise, intermittent Constant noise Dust

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Silica, asbestos, etc.

Fumes, smoke, or gases Solvents (degreasing agents) Grease and oils Radiant energy

Slippery or uneven walking surfaces Electrical energy

Working around machinery with moving

Working around moving objects or vehicles parts

11.

12.

13.

14.

15.

16.

17.

18.

19.

Working on ladders or scaffolding Working below ground Unusual fatigue factors (specify) Working with hands in water Explosives Vibration Working closely with others Working alone Protracted or irregular hours of work Other (specify)

21.

22.

23.

24.

25.

26.

27.

28.

29.

20.

znn2228 Highlight znn2228 Highlight znn2228 Highlight znn2228 Highlight znn2228 Highlight znn2228 Highlight znn2228 Highlight znn2228 Highlight znn2228 Highlight znn2228 Highlight znn2228 Highlight znn2228 Highlight znn2228 Highlight znn2228 Highlight znn2228 Highlight

Jaeger No. 2 Type

3.

250 500 1000 2000 3000 4000 5000 6000 7000 8000

4.

a. Abdomen

Head and back (including face, hair, and scalp) Peripheral blood vessels

Speech (note any malfunction) Extremities

Skin and lymph nodes (including thyroid gland) Urinalysis (if indicated)

Respiratory tract (X-ray if indicated)

Back (special consideration for positions involving heavy lifting and other strenuous duties)

Neurological and mental Health

Jaeger No. 2 Type

No limiting conditions for this job

YES

YES

NO

NO

EARS: (Consider denominators indicated here as normal. Record as numerators the greatest distance heard.)

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.

EYES:1.

(A) (B)

Distant vision (Snellen): without glasses: right left

Test each eye separately.

; with glasses, if worn; right left What is the longest and shortest distance at which the following specimen of Jaeger No. 2 type can be read by the applicant?

20 20 20 20 employees in the Federal classified service as may be required by the Civil Service Commission or its author-ized representative. This order will supplement the Ex-ecutive Orders of May 29 and June 18, 1923 (Executive Order, September 4, 1924).

without glasses:

L in. to

R in.

in. to in.

with glasses, if used:

L in. to

R in.

in. to in.

(B) 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?

Ordinary conversation: Audiometer (if given):

RIGHT EAR ; LEFT EAR

20 ft. 20 ft.

OTHER FINDINGS: In items a through l briefly describe any abonormality (including diseases, scars, and disfigurations). Include brief history, if pertinent. If normal, so indicate.

Eyes, ears, nose, and throat (including tooth and oral hygiene) b.

c.

d.

e.

f.

g.

h.

Sp. gr.

Albumen

Sugar Casts

Blood Pus i.

j. Heart (size, rate, rhythm, function) Blood pressure Pulse EKG (if indicated) k.

l.

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.

Limiting conditions as follows

FOR AGENCY USE ONLY

Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

1. NAME (last, first, middle) SOCIAL SECURITY ACCOUNT NO. SEX DATE OF BIRTH

DO YOU HAVE ANY MEDICAL DISCORDER OR PHYSICAL

(Signature of applicant)

2. 3.

MALE

FEMALE

4.

5.

IMPAIRMENT WHICH WOULD INTERFERE IN ANY WAY WITH

THE FULL PERFORMANCE OF THE DUTIES SHOWN BELOW?

YES NO

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

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.

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-appointmentpurposes, circle the appropriate handicap code in part F.

1. RECOMMENDATION:

HIRE OR RETAIN, DESCRIBE LIMITATIONS, IF ANY, HERE.

TAKE ACTION TO SEPARATE OR DO NOT HIRE, EXPLAIN WHY

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-appointmentpurposes, 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 separtely or together.

1. ACTION TAKEN:

HIRED OR RETAINED

ACTION TAKEN TO SEPARATE

NON-SELECTED FOR APPOINTMENT, OR ELIGIBILITY OBJECTED TO.

AGENCY PERSONNEL OFFICER'S NAME (Type or print)2. SIGNATURE DATE3. 4.

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".

No handicap of the type listed Amputations-one major extremity Amputation-two or more major extremities Deformity or impaired function-upper

Deformity or impaired function-lower

Vision-one eye only No usable vision extremity extremity or back

Hearing aid required No usable hearing No usable hearing, with speech malfunction Normal hearing, with speech malfunction

Tuberculosis-inactive pulmonary Organic heart disease (compensated)-Val-vular, arrhythmia, arteriosclerosis, healed coronary lesions

Diabetes-controlled Epilepsy-adequately controlled History of emotional behavioral problems

Mentally retarded Mentally restored requiring special placement effort

1. EXAMINING PHYSICIAN'S NAME (type or print)

ADDRESS (including ZIP Code)2.

SIGNATURE OF EXAMINING PHYSICIAN3.

(signature) (date)

IMPORTANT: After signing, return the entire form intact in the pre-addressed "Confidential-Medical" envelope which the person you exam-ined gave you.