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.

Check this box when there is an additional functional requirement not listed above and enter that requirement on line 1.

Check this box when there is an additional functional requirement not listed above and enter that requirement on line 2.

Check this box when there is an additional functional requirement not listed above and enter that requirement on line 3.

Check this box when there is an additional functional requirement not listed above and enter that requirement on line 4.

Check this box when there is an additional functional requirement not listed above and enter that requirement on line 5.

Check this box when there is an additional functional requirement not listed above and enter that requirement on line 6.

Check this box when there is an additional functional requirement not listed above and enter that requirement on line 7.

Check this box when there is an additional functional requirement not listed above and enter that requirement on line 8.

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 date at the bottom of the form on page 5.

Enter your full name as requested on the form (Last name, First name, Middle initial).

Enter the last four digits of your Social Security Number.

Enter the date you completed or signed this page.

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 applicant's full printed name to indicate their consent and certification of the information on this form.

Enter the date when the applicant signed or certified the information on this form.

Enter your full name as Last name, First name, and Middle initial (if any).

Enter your federal employee number or agency-assigned identification number.

Enter the applicant's date of birth.

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 digital signature of the applicant or employee to confirm consent.

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

Enter the primary email address where you can be contacted.

Enter one or more phone numbers including area code(s) for contact (separate multiple numbers with commas).

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

Check this box if the job requires working outdoors.

Check this box if the job requires working both outdoors and indoors.

Check this box if the job exposes the worker to excessive heat.

Check this box if the job exposes the worker to excessive cold.

Check this box if the job involves exposure to excessive humidity.

Check this box if the job involves conditions of excessive dampness or chilling.

Check this box if the job involves working in dry atmospheric conditions.

Check this box if the job exposes the worker to intermittent excessive noise.

Check this box if the job exposes the worker to constant noise.

Check this box if the job involves exposure to dust.

Check this box if the job involves exposure to silica, asbestos, or similar hazardous particulates.

Check this box if the job involves exposure to fumes, smoke, or gases.

Check this box if the job involves exposure to solvents or degreasing agents.

Check this box if the job involves exposure to grease or oils.

Check this box if the job involves exposure to radiant energy (e.g., intense light or heat radiation).

Check this box if the job involves working with or near electrical energy.

Check this box if the job requires walking on slippery or uneven surfaces.

Check this box if the job requires working around machinery that has moving parts.

Check this box if the job requires working around moving objects or vehicles.

Check this box if the job requires working on ladders or scaffolding.

Check this box if the job requires working below ground level (e.g., trenches, tunnels).

Check this box if there are unusual fatigue factors affecting the job and specify them on the line provided.

Check this box if the job requires frequent or prolonged use of hands in water.

Check this box if the job involves handling or working near explosives.

Check this box if the job exposes the worker to vibration (from tools, equipment, or vehicles).

Check this box if the job requires working in close physical proximity to other people.

Check this box if the job frequently requires the worker to perform tasks alone without nearby coworkers.

Check this box if the job requires protracted (long) or irregular work hours or shifts.

Check this box to indicate an environmental factor not listed above and write the specific factor on the adjacent line.

Check this box to indicate an environmental factor not listed above and write the specific factor on the adjacent line.

Check this box to indicate an environmental factor not listed above and write the specific factor on the adjacent line.

Check this box to indicate an environmental factor not listed above and write the specific factor on the adjacent line.

Check this box to indicate an environmental factor not listed above and write the specific factor on the adjacent line.

Check this box to indicate an environmental factor not listed above and write the specific factor on the adjacent line.

Check this box to indicate an environmental factor not listed above and write the specific factor on the adjacent line.

Check this box to indicate an environmental factor not listed above and write the specific factor on the adjacent line.

Enter the first additional environmental factor or hazard not listed above, briefly describing the condition or exposure.

Enter the second additional environmental factor or hazard not listed above, briefly describing the condition or exposure.

Enter the third additional environmental factor or hazard not listed above, briefly describing the condition or exposure.

Enter the fourth additional environmental factor or hazard not listed above, briefly describing the condition or exposure.

Enter the fifth additional environmental factor or hazard not listed above, briefly describing the condition or exposure.

Enter the sixth additional environmental factor or hazard not listed above, briefly describing the condition or exposure.

Enter the seventh additional environmental factor or hazard not listed above, briefly describing the condition or exposure.

Enter the eighth additional environmental factor or hazard not listed above, briefly describing the condition or exposure.

Enter the ninth additional environmental factor or hazard not listed above, briefly describing the condition or exposure.

Enter a brief description of the specific unusual fatigue factor(s) observed or reported that could affect job performance (e.g., persistent tiredness, sudden episodes of extreme fatigue), using plain language. Fill only if 'Unusual fatigue factors (specify)' is 'Yes'.

Check this box when an environmental factor relevant to the position is not listed elsewhere and you will specify the additional factor on the adjacent blank line.

Check this box when the examination is being performed as a pre-placement medical evaluation before hiring or assignment.

Check this box when the purpose of the examination is something other than pre-placement, and provide the specific purpose in the adjacent text field.

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 you completed or signed this form section.

Enter the date associated with this form, for example the date the applicant completed or signed the form.

Check this box if the position requires repeated bending as an essential function (specify number of hours in the blank).

Check this box if the job requires climbing using legs only as an essential function (specify number of hours in the blank).

Check this box if the position requires climbing that uses both legs and arms as an essential function.

Check this box if the ability to use both legs is essential to perform the job duties.

Check this box if operating a crane, truck, tractor, or other motor vehicle is an essential duty of the position.

Check this box if the job requires simultaneous rapid mental and muscular coordination as an essential requirement.

Check this box if the position requires or benefits from the ability to use firearms or if firearms use is desirable for the role.

Enter the number of hours the position requires performing repeated bending (average per workday or per shift as applicable). Fill only if 'Repeated bending' is 'Yes'.

Enter the number of hours the position requires climbing using legs only (average per workday or per shift as applicable). Fill only if 'Climbing, legs only' is 'Yes'.

Provide a clear description of any specific visual requirements for the job (for example: color discrimination, near or distance acuity, depth perception, or other detailed vision needs). Fill only if 'Specific visual requirement (specify)' is 'Yes'.

Enter the number of hours the position requires performing straight pulling. Fill only if 'Straight pulling (_____hours)' is 'Yes'.

Enter the number of hours the position requires performing pulling hand-over-hand. Fill only if 'Pulling hand over hand (_____hours)' is 'Yes'.

Enter the number of hours the position requires performing pushing. Fill only if 'Pushing (_____hours)' is 'Yes'.

Enter the number of hours the position requires walking. Fill only if 'Walking (_____hours)' is 'Yes'.

Enter the number of hours the position requires standing. Fill only if 'Standing (_____hours)' is 'Yes'.

Enter the number of hours the position requires crawling. Fill only if 'Crawling (_____hours)' is 'Yes'.

Enter the number of hours the position requires kneeling. Fill only if 'Check this box if outside is an environmental factor' is 'Yes'.

Enter any specific hearing requirements for the position (for example required hearing acuity, permitted use of a hearing aid, or other hearing-related constraints). Fill only if 'Specific hearing requirements (specify)' is 'Yes'.

Provide an additional vision or hearing functional requirement not covered by the checkboxes, described briefly on this line.

Provide an additional vision or hearing functional requirement not covered by the checkboxes, described briefly on this line.

Provide an additional vision or hearing functional requirement not covered by the checkboxes, described briefly on this line.

Provide an additional vision or hearing functional requirement not covered by the checkboxes, described briefly on this line.

Provide an additional vision or hearing functional requirement not covered by the checkboxes, described briefly on this line.

Provide an additional vision or hearing functional requirement not covered by the checkboxes, described briefly on this line.

Provide an additional vision or hearing functional requirement not covered by the checkboxes, described briefly on this line.

Provide an additional vision or hearing functional requirement not covered by the checkboxes, described briefly on this line.

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.

Check this box when the position requires normal hearing but the use of a hearing aid is acceptable to meet the hearing requirement.

Check this box when the position requires the individual to meet hearing standards unaided, without the use of any hearing aid.

Check this box when there are particular or nonstandard hearing requirements for the job that must be described in the provided space.

Check this box if the position requires lifting 45 pounds or more.

Check this box if the position requires lifting between 15 and 44 pounds.

Check this box if the position requires lifting under 15 pounds.

Check this box if the position requires carrying 45 pounds or more.

Check this box if the position requires carrying between 15 and 44 pounds.

Check this box if the position requires carrying under 15 pounds.

Check this box if the position requires straight pulling and enter the number of hours.

Check this box if the position requires hand‑over‑hand pulling and enter the number of hours.

Check this box if the position requires pushing and enter the number of hours.

Check this box if the position requires reaching above shoulder level.

Check this box if the position requires repetitive or precise use of the fingers (fine motor skills).

Check this box if the position requires use of both hands.

Check this box if the position requires walking and enter the typical number of hours.

Check this box if the position requires standing and enter the typical number of hours.

Check this box if the position requires crawling and enter the number of hours.

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 medical disorder or physical impairment that may interfere with your ability to perform the duties shown in Part B, Number 3, including relevant details such as diagnosis, symptoms, severity, date of onset, treatments, and any limitations. Fill only if 'Yes' is 'Yes'.

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

Check this box if you have any medical disorder or physical impairment which may interfere in any way with the full performance of duties shown in Part B, Number 3.

Check this box if you do not have any medical disorder or physical impairment which may interfere in any way with the full performance of duties shown in Part B, Number 3.

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.

Check this box if the applicant's sex is male.

Check this box if the applicant's sex is female.

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 your full name in the order Last, First, Middle Initial exactly as you want it to appear on the form.

Enter only the final four digits of your Social Security Number, without dashes or spaces.

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 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 official position title followed by the job series and grade (e.g., 'Program Analyst, GS-0343-12').

Provide a concise summary of the primary duties and responsibilities the position requires the employee to perform, including typical tasks and any physical or mental demands.

Provide a brief text description specifying the purpose of the examination when it is not 'Pre-placement' (e.g., 'Annual review', 'Return-to-duty', 'Fitness for duty'). Fill only if 'Other (Specify)' is 'Yes'.

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 the position requires near vision that is correctable at 13 to 16 inches to Jaeger 1–4.

Check this box if the position requires far vision correctable to 20/20 in one eye and 20/40 in the other.

Check this box when there is a specific visual requirement not listed and provide the required details on the line provided.

Check this box if the job requires binocular vision (use of both eyes).

Check this box if the position requires the ability to perceive depth accurately.

Check this box if the job requires the ability to distinguish basic colors.

Check this box if the position requires distinguishing subtle shades or variations of color.

Enter the applicant's blood pressure reading.

Enter the applicant's pulse rate.