UNIVERSITY OF THE PHILIPPINES

Diliman, Quezon City

HUMAN RESOURCES DEVELOPMENT OFFICE

Date

The Director
University Health Service
University of the Philippines
Diliman, Quezon City

Dear Director ______________________:

This is to introduce ________________________________________________ a

prospective employee/faculty in this University, whom we are referring to your office for
physical and medical examination. Position to be filled (Original/Permanent).

Please notify this Office as to the result of the examination. (Form Attached)

Very truly yours,

For the Director:

INSTRUCTION FOR PRE-EMPLOYMENT/PERMANENCY/PHYSICAL/MEDICAL

EXAMINATION

To facilitate the completion of your physical and medical examination, be

sure to submit as early as possible to the University Health Service the following:

1. Fresh specimen of
a) Urine
b) Feces

2. A certification of the last X-ray you had, if any

3. Medical Fee (For original/reappointment only)
CS Form No. 211
Revised 2017

MEDICAL CERTIFICATE
(For Employment)

INSTRUCTIONS
a. This medical certificate should be accomplished by a licensed government physician.
b. Attach this certificate to original appointment, transfer and reemployment.
c. The results of the following pre-employment medical/physical/mental examinations
must be attached to this form:
Blood Test
Urinalysis
Chest X-Ray
Drug Test
Psychological Test
Neuro-Psychiatric Examination (if applicable)

FOR THE PROPOSED APPOINTEE

NAME (Last Name, First Name, Name Extension (if any) and Middle Name) AGENCY / ADDRESS

ADDRESS

AGE SEX CIVIL STATUS PROPOSED POSITION

FOR THE LICENSED GOVERNMENT PHYSICIAN

I hereby certify that I have reviewed and evaluated the attached examination results, personally examined the
above named individual and found him/her to be physically and medically £FIT / £UNFIT for employment.
SIGNATURE over PRINTED NAME OF LICENSED GOVERNMENT PHYSICIAN: OTHER INFORMATION ABOUT THE
PROPOSED APPOINTEE

AGENCY/Affiliation of Licensed Government Physician:

LICENSE NO. HEIGHT (M) WEIGHT (KG) BLOOD

Bare Foot Stripped TYPE

OFFICIAL DESIGNATION DATE EXAMINED