Form MRP-5 Self - Certification Medical Statement

(MRP Directive 4339.1 Attachment)

According to the Paperwork Reduction Act of 1995, no persons are required to re spond to a collection of information unless it displays a valid OMB control num ber. The valid
OMB control number for this information collection is 0579-0196. The time requ ired to complete this information collection is estimated to average .0167 hour s per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the co llection of
information.

UNITED STATES DEPARTMENT OF AGRICULTURE
MARKETING AND REGULATORY PROGRAMS

SELF - CERTIFICATION
MEDICAL STATEMENT

OMB No.
0579-0196

Expiration Date: XXX-XXXX

INSTRUCTIONS TO APPLICANT: Please read instructions for each section carefully
before answering the question. Type or print answers in ink. If additional space is
required to provide details use Section D on page 4. After completing this statement be
sure to sign your name and give the date in Section E. Your replies will be evaluated in
terms of the particular position for which you are applying. NOTE: At the discretion of the
appointing officer, a medical examination at the Government's expense may be required.

PRIVACY ACT STATEMENT
Solicitation of this information is authorized by Section 3301 of Title 5, U.S. Code, which provides for a determination as to an individual's fitness for
employment with regard to age, health, and physical ability. This information will be used in determining your fitness and ability to perform duties of the
position for which you are applying.
Executive Order 9397 (Numbering System of Federal Accounts Relating to Individual Persons) authorizes the collection of your social security number
(SSN). Your SSN is used to ensure that the information you provide is accurately recorded as pertaining to you. Furnishing your SSN or any of the
other data is voluntary. However, failure to provide complete and accurate information may limit consideration or jeopardize eligibility to hold a Federal
position.
IDENTIFICATION OF APPLICANT

NAME (Last, First, Middle)

Date of Birth (Month, Day, Year)

ADDRESS (Number, Street, City, State and Zip)

TITLE OF POSITION APPLIED FOR

SOCIAL SECURITY NUMBER

SECTION A - PHYSICAL LIMITATIONS

Answer each item "YES" or "NO" by placing an "X" in the proper box below. If you answer "NO" to any item, give additional details in Section D.

YES
1. Can you read small newspaper print (corrective lenses permitted)?
2. Can you distinguish basic colors (red, green, blue)?
3. Can you distinguish shades of colors?
4. Can you distinguish normal tastes and smells?
5. Can you communicate effectively and independently by telephone?

MRP FORM 5-R
MAY 2003

PREVIOUS EDITIONS ARE TO BE DESTROYED
(LOCAL REPRODUCTION AUTHORIZED )

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NO

SECTION B - PHYSICAL ENDURANCE FACTOR
Answer each item "YES" or "NO" by placing an "X" in the proper box below to show your physical ability to carry out the listed activities during each workday. If you answer
"NO" to any item, give additional details in Section D.

During the workday are you able to perform activities involving the following:

YES

1. Sitting for long periods of time?...............................................................................................
2. Standing for long periods of time?..........................................................................................
3. Some walking on flat surfaces, slight inclines, and occasionally climbing stairs?..................
4. Frequent walking and/or climbing stairs or steep inclines?....................................................
5. Continuous pulling (_____hours)?..........................................................................................
6. Occasional pushing and pulling ..............................................................................................
7. Frequent pushing and pulling motions?...................................................................................
8. Occasional bending, stooping, and crouching?.....................................................................
9. Frequent bending, stooping, and crouching?.........................................................................
10. Lifting and carrying under 15 pounds?.................................................................................
11. Lifting and carrying 15 to 44 pounds?..................................................................................
12. Lifting and carrying 45 pounds or over?..............................................................................
13. Reaching above shoulders?................................................................................................
14. Repeated bending (_____hours)?........................................................................................
15. Standing (______hours)?.....................................................................................................
16. Crawling (_______hours)?...................................................................................................
17. Kneeling (_______hours)?....................................................................................................
18. Climbing, use of arms and legs?............................................................................................
19. Operating a motor vehicle?....................................................................................................
20. Working under pressure and time constraints?....................................................................
21. Performing rapid mental and muscular coordination simultaneously?...................................

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NO

SECTION C - ENVIRONMENTAL ENDURANCE FACTOR
Some positions may involve unusual working conditions or working outside. Answer each item "YES" or "NO" by placing an "X" in the proper box below. If you answer "NO"
to any item, give additional details in Section D.

Can you work under the following conditions:

YES

NO

1. Outside and inside?
2. Severe heat?
3. Severe cold?
4. Severe humidity?
5. Severe dampness or chilling?
6. Dry atmospheric conditions?
7. Severe noise?
8. Constant noise?
9. Dusty atmosphere?
10. Some exposure to fumes, smoke, or gases?
11. Some (incidental) contact with solvents, greases, and oils?
12. Some contact with laboratory substances or chemicals?
13. Working with hands in water?
14. Occasional walking over rough terrain?
15. Slippery or uneven walking surfaces?
16. Around machinery with moving parts?
17. Around moving objects or vehicles?
18. Climbing ladders/scaffolding?
19. Working below ground surface?
20. Working alone?
21. Working closely with others?
22. Protracted or irregular hours of work?
23. Commercial air travel?
24. Rotating shifts?
25. Nights?

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SECTION D - ADDITIONAL DETAILS
This space is for detailed answers to Section A, B, and C and any additional information you may wish to provide. (Give section letter and item number.)

SECTION
LETTER/ITEM
NUMBER

SECTION
LETTER/ITEM
NUMBER

DESCRIPTION

DESCRIPTION

IF YOU NEED MORE SPACE, ATTACH ADDITIONAL SHEETS
SECTION E - CERTIFICATION BY APPLICANT

I certify that all the information I have furnished is correct to the best of my knowledge and belief.
APPLICANT (Signature)

DATE SIGNED (Month, Day, Year)

SECTION F - AGENCY USE ONLY
1. POSITION TO WHICH APPLICANT ASSIGNED

2. OTHER ACTION TAKEN

4. SIGNATURE OF APPOINTING OFFICER

5. OFFICIAL TITLE

3. DATE SIGNED (Month, Day, Year)

6. ADDRESS OF AGENCY

INSTRUCTIONS TO THE AGENCY
This document may be used in conjunction with or in lieu of a Certification of Medical Examination for positions whose physical requirements do not exceed those
identified on the questionnaire, and which may properly be evaluated by an appointing officer.
If, either as a result of replies on the document or a personal observation, th e appointing officer believes the applicant is physically unable to do the job or would create a
hazard to himself, herself, or others, the appointing officer may require the a pplicant to undergo a medical examination. (The examination may not be require d solely on the
basis of the applicant's age, sex, or other non job-related factor.) In additi on, for positions having unusual sight or hearing requirements, an appropriate specialized
examination, at the Government's expense, may be required.

AGENCY OFFICIAL WILL:
1. Fill in "Title of Position Applied For " under "IDENTIFICATION OF APPLICANT."
2. Circle the item number of the questions, in each section, which will determine the applicant's ability to perform the duties of the position. Circle ONLY those items which
pertain to the physical requirements of the job, or in the case of Section C, the environmental factors.
3. After the applicant completes the statement, take appropriate action as ind icated by the applicant's replies. A Federal medical officer should be consult ed when indicated
by detailed replies.
4. In accordance with 5 CFR 339.306, the appointing officer is authorized to medically disqualify a nonpreference eligible. If the candidate is a preference eligible, OPM
must approve the agency's determination to pass over the preference eligible on that ground. The appointing officer must request a medical examination. He/s he must then
submit the entire record (including the SF-78, Certificate of Medical Examinati on; the MRP-5-R, Self-Certification Medical Statement; and the candidate's application and/or
resume for Federal Employment, if available) with the SF-62, Agency Request to Pass Over a Preference Eligible or Object to an Eligible, to the Office of Personnel
Management, for a decision.

MRP FORM 5-R
MAY 2003

(LOCAL REPRODUCTION AUTHORIZED)

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