Form OF-178, Certificate of Medical Examination Instructions

Select this option if the action taken is to hire or retain the individual.

Select this option if the action taken is non-selection for appointment.

Select this option if the action taken is to separate the individual.

Indicate if there is another specific functional requirement necessary for the position.

Specify the additional functional requirement necessary for the position.

Indicate if there is another specific functional requirement necessary for the position.

Specify the additional functional requirement necessary for the position.

Indicate if there is another specific functional requirement necessary for the position.

Specify the additional functional requirement necessary for the position.

Indicate if there is another specific functional requirement necessary for the position.

Specify the additional functional requirement necessary for the position.

Indicate if there is another specific functional requirement necessary for the position.

Specify the additional functional requirement necessary for the position.

Indicate if there is another specific functional requirement necessary for the position.

Specify the additional functional requirement necessary for the position.

Indicate if there is another specific functional requirement necessary for the position.

Specify the additional functional requirement necessary for the position.

Indicate if there is another specific functional requirement necessary for the position.

Specify the additional functional requirement necessary for the position.

Enter the name of the agency HR officer.

Enter the e-mail address of the agency HR officer.

Provide the complete address of the agency HR officer, including street, city, state, and zip code.

Enter the phone number of the agency HR officer.

Provide the digital signature of the agency HR officer.

Enter or select the date when the agency HR officer digitally signed this form.

Provide the complete address of the agency medical officer, including street, city, state, and zip code.

Enter the phone number of the agency medical officer.

Provide the digital signature of the agency medical officer.

Enter or select the date when the agency medical officer digitally signed this form.

Enter the name of the agency medical officer.

Enter the email address of the agency medical officer.

Enter the name of the applicant or employee.

Enter the last four digits of the applicant's or employee's Social Security Number.

Select 'Yes' if the applicant can distinguish red, green, and yellow colors.

Select 'No' if the applicant cannot distinguish red, green, and yellow colors.

Select 'Yes' if the applicant has passed the color vision test.

Select 'No' if the applicant has not passed the color vision test.

Enter the name of the applicant or employee to provide consent for the medical examination.

Enter the digital signature of the applicant or employee to confirm consent.

Enter the date when the applicant or employee signed the form, in the format: month, day, year, or select it from the dropdown menu.

Enter your full street address, including city, state, and zip code.

Enter your email address for contact purposes.

Enter your 10-digit telephone number for contact purposes.

Enter your Federal Employee Number, which is a unique identifier for federal employees.

Enter the position title, series, and grade of the applicant or employee.

Provide a brief description of the position held or applied for by the applicant or employee.

Check this box if working outside is an environmental factor for the job.

Indicate if working outside is an environmental factor for the position.

Indicate if working both outside and inside are environmental factors for the position.

Indicate if heat is a significant environmental factor affecting the job position.

Indicate if cold is a significant environmental factor affecting the job position.

Indicate if humidity is a significant environmental factor affecting the job position.

Indicate if dampness or chilling is a significant environmental factor affecting the job position.

Indicate if dry conditions are a significant environmental factor affecting the job position.

Indicate if excessive or intermittent noise is a significant environmental factor affecting the job position.

Indicate if constant noise is a significant environmental factor affecting the job position.

Indicate if dust is a significant environmental factor affecting the job position.

Indicate if exposure to silica, asbestos, or similar substances is a significant environmental factor affecting the job position.

Indicate if fumes, smoke, or gases are significant environmental factors affecting the job position.

Indicate if exposure to grease and oils is a significant environmental factor affecting the job position.

Indicate if exposure to grease and oils is a significant environmental factor affecting the job position.

Indicate if exposure to radiant energy is a significant environmental factor affecting the job position.

Indicate if exposure to electrical energy is a significant environmental factor affecting the job position.

Indicate if machinery with moving parts is a significant environmental factor affecting the job position.

Indicate if moving objects or vehicles are significant environmental factors affecting the job position.

Indicate if moving objects or vehicles are significant environmental factors affecting the job position.

Indicate if being below ground is a significant environmental factor affecting the job position.

Indicate if being below ground is a significant environmental factor affecting the job position.

Indicate if unusual fatigue factors are significant environmental factors affecting the job position.

Specify any unusual fatigue factors that are significant environmental factors affecting the job position.

Indicate if having your hands in water is a relevant environmental factor for your job position.

Indicate if exposure to explosives is a relevant environmental factor for your job position.

Indicate if exposure to vibration is a relevant environmental factor for your job position.

Indicate if working closely with others is a relevant environmental factor for your job position.

Indicate if working alone is a relevant environmental factor for your job position.

Indicate if working irregular hours is a relevant environmental factor for your job position.

Indicate if there is another specific environmental requirement relevant to your job position.

Specify the additional environmental requirement relevant to your job position.

Indicate if there is another specific environmental requirement relevant to your job position.

Specify the additional environmental requirement relevant to your job position.

Indicate if there is another specific environmental requirement relevant to your job position.

Specify the additional environmental requirement relevant to your job position.

Indicate if there is another specific environmental requirement relevant to your job position.

Specify the additional environmental requirement relevant to your job position.

Indicate if there is another specific environmental requirement relevant to your job position.

Specify the additional environmental requirement relevant to your job position.

Indicate if there is another specific environmental requirement relevant to your job position.

Specify the additional environmental requirement relevant to your job position.

Indicate if there is another specific environmental requirement relevant to your job position.

Specify the additional environmental requirement relevant to your job position.

Indicate if there is another specific environmental requirement relevant to your job position.

Specify the additional environmental requirement relevant to your job position.

Check this box if there is an additional specific environmental requirement that applies to the applicant or employee.

Specify any additional environmental requirement that applies to the applicant or employee.

Select this option if the purpose of the examination is for pre-placement.

Select this option if the purpose of the examination is for reasons other than pre-placement.

Specify the purpose of the examination if it is for reasons other than pre-placement.

Click this button to print the form.

Click this button to save the form.

Click this button to clear all fields in the form.

Enter the date at the bottom of the form. This is typically the date the form is completed.

Enter the date at the bottom of the form, indicating when the form was completed.

Enter the date at the bottom of the form, indicating when the form was completed.

Enter the date located at the bottom of the form.

Enter the date at the bottom of the form on page 5.

Enter the date at the bottom of the form on page 6.

Check this box if repeated bending is a necessary function of the job.

Check this box if climbing using only legs is a necessary function of the job.

Check this box if climbing using both legs and arms is a necessary function of the job.

Check this box if having both legs is a necessary function of the job.

Check this box if operating a motor vehicle is a necessary function of the job.

Check this box if rapid, simultaneous mental and muscular coordination is a necessary function of the job.

Check this box if the ability to use firearms is a necessary function of the job.

Enter the hearing test result number for the right ear from a distance of 20 feet.

Enter the hearing test result number for the left ear from a distance of 20 feet.

Indicate if hearing with a hearing aid is a necessary functional requirement for the position.

Indicate if hearing without a hearing aid is a necessary functional requirement for the position.

Indicate if there are specific hearing requirements that are necessary for the position.

Provide details about any additional hearing requirements needed for the position.

Check this box if heavy lifting is a requirement for the job position.

Check this box if moderate lifting is a requirement for the job position.

Check this box if light lifting is a requirement for the job position.

Check this box if heavy carrying is a requirement for the job position.

Check this box if moderate carrying is a requirement for the job position.

Check this box if light carrying is a requirement for the job position.

Check this box if straight pulling is a requirement for the job position.

Enter the number of hours per day that straight pulling is required for the job position.

Check this box if hand over hand pulling is a requirement for the job position.

Enter the number of hours per day that hand over hand pulling is required for the job position.

Check this box if reaching above the shoulder is a requirement for the job position.

Enter the number of hours per day that pushing is required for the job position.

Check this box if reaching above the shoulder is a requirement for the job position.

Check this box if using your fingers is a requirement for the job position.

Check this box if having both hands is a requirement for the job position.

Check this box if walking is a requirement for the job position.

Enter the number of hours per day that walking is required for the job position.

Check this box if standing is a requirement for the job position.

Enter the number of hours per day that standing is required for the job position.

Check this box if crawling is a requirement for the job position.

Provide details about any abnormalities found in the urinalysis. If no abnormalities are present, indicate that the urinalysis is normal.

Enter the specific gravity (SP. Gr) results from the urinalysis.

Enter the sugar level results from the urinalysis.

Enter the blood albumen level results from the urinalysis.

Enter the results for casts found in the urinalysis.

Enter the results for pus found in the urinalysis.

Enter the results of the applicant's EKG, including any abnormalities.

Select 'Yes' if the applicant has passed the lantern test.

Select 'No' if the applicant has not passed the lantern test.

Describe any abnormalities found in the eyes, ears, nose, and throat. If there are no abnormalities, indicate that the examination was normal.

Select this option if the applicant or employee has a medical disorder or physical impairment.

Select this option if the applicant or employee does not have a medical disorder or physical impairment.

Provide a description of any medical disorder or physical impairment the applicant or employee has.

Select this option if there are no medical limitations for the applicant.

Select this option if there are medical limitations for the applicant, as detailed in section 20 below.

Describe any medical findings that would limit the applicant's ability to perform the job. Indicate 'None' if there are no limitations.

Select this option if the applicant is medically qualified for the position.

Provide a brief explanation of why the applicant is medically qualified.

Select this option if the applicant is qualified with accommodations.

Provide a brief explanation of why the applicant is qualified with accommodations and list the restrictions.

Select this option if the applicant is medically disqualified.

Provide a brief explanation of why the applicant is medically disqualified.

Enter the name of the applicant or employee who is undergoing the medical examination.

Enter the last four digits of the applicant's or employee's Social Security Number.

Enter your full name in the format: last name, first name, and middle initial.

Select this option if the applicant or employee is male.

Select this option if the applicant or employee is female.

Enter your birth date in the format: month, day, year, or select it from the dropdown menu.

Enter the name of the applicant or employee who is undergoing the medical examination.

Enter the last four digits of your Social Security Number.

Enter the full name of the applicant or employee undergoing the medical examination.

Enter the last four digits of the applicant or employee's Social Security Number.

Enter the name of the applicant or employee undergoing the medical examination.

Enter the last four digits of the applicant's or employee's Social Security Number.

Enter the name of the applicant or employee undergoing the medical examination.

Enter the last four digits of the applicant's or employee's Social Security Number.

Provide details about any abnormalities found in the abdomen during the examination. If no abnormalities are present, indicate that the abdomen is normal.

Provide details about any abnormalities found in the head and back, including the face, hair, and scalp. If no abnormalities are present, indicate that these areas are normal.

Provide details about any abnormalities found in the peripheral blood vessels. If no abnormalities are present, indicate that the blood vessels are normal.

Provide details about any abnormalities or malfunctions with speech. If no abnormalities are present, indicate that speech is normal.

Provide details about any abnormalities with the extremities, including issues with strength and range of motion. If no abnormalities are present, indicate that the extremities are normal.

Provide details about any abnormalities with the skin and lymph nodes, including the thyroid gland. If no abnormalities are present, indicate that these areas are normal.

Provide details about any abnormalities found in the respiratory tract. If no abnormalities are present, indicate that the respiratory tract is normal.

Provide details about any abnormalities found in the heart, including issues with size, rate, rhythm, and function. If no abnormalities are present, indicate that the heart is normal.

Provide details about any abnormalities found in the back. If no abnormalities are present, indicate that the back is normal.

Provide details about any neurological and mental health abnormalities, including issues with reflexes and sensation. If no abnormalities are present, indicate that these areas are normal.

Enter the feet component of the applicant or employee's height. For example, enter '5' if the height is 5 feet 10 inches.

Enter the inches component of the applicant or employee's height. For example, enter '10' if the height is 5 feet 10 inches.

Enter the weight of the applicant or employee in pounds.

Enter the total number of hours per week that the job requires crawling.

Enter the total number of hours per week that the job requires kneeling.

Enter the total number of hours per week that the job requires repeated bending.

Enter the total number of hours per week that the job requires climbing using only legs.

Enter the full name of the examining physician.

Enter the email address of the examining physician.

Enter the complete address of the examining physician, including street, city, state, and zip code.

Enter the phone number of the examining physician.

Provide the digital signature of the examining physician.

Enter or select the date when the examining physician digitally signed the form.

Enter the denominator of the right eye's vision without corrective lenses, in the format '20 over'.

Enter the denominator of the left eye's vision without corrective lenses, in the format '20 over'.

Enter the denominator of the right eye's vision with corrective lenses, in the format '20 over'.

Enter the denominator of the left eye's vision with corrective lenses, in the format '20 over'.

Enter the type of test used to assess depth perception.

Enter the seconds of arc measurement for depth perception.

Enter the number of items the applicant got correct in the vision test.

Enter the total number of items tested in the vision test.

Select this option if the interpretation of the vision test results is normal.

Select this option if the interpretation of the vision test results is abnormal.

Enter the number of degrees for the right nasal field of vision.

Enter the number of degrees for the right temporal field of vision.

Enter the number of degrees for the left nasal field of vision.

Enter the number of degrees for the left temporal field of vision.

Enter the initial measurement in inches for the left eye's vision without using corrective lenses.

Enter the final measurement in inches for the left eye's vision without using corrective lenses.

Enter the initial measurement in inches for the right eye's vision without using corrective lenses.

Enter the final measurement in inches for the right eye's vision without using corrective lenses.

Enter the initial measurement in inches for the left eye's vision with corrective lenses.

Enter the final measurement in inches for the left eye's vision with corrective lenses.

Enter the initial measurement in inches for the right eye's vision with corrective lenses.

Enter the final measurement in inches for the right eye's vision with corrective lenses.

Check this box if near vision measurements are a necessary function of the job.

Check this box if far vision measurements are a necessary function of the job.

Check this box if specific visual requirements are necessary for the job.

Specify any additional visual requirements needed for the job.

Check this box if having both eyes is a necessary function of the job.

Check this box if the ability to distinguish basic colors is a necessary function of the job.

Check this box if the ability to distinguish basic colors is a necessary function of the job.

Check this box if the ability to distinguish shades of colors is a necessary function of the job.

Enter the applicant's blood pressure reading.

Enter the applicant's pulse rate.