Form OF 178 OF 178 Certificate of Medical Examination

To be given to the individual
examined with a pre-addressed
envelope marked
“Confidential - Medical”.

CERTIFICATE OF MEDICAL EXAMINATION
U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved
OMB No. 3206 - 0250

Privacy Act Statement
Solicitation of this information is authorized by Section 552a of Title 5, United States Code, regarding records maintained on
individuals; Section 3301 of Title 5, United States Code, regarding determination as to an individual's fitness for employment with
regard to age, health, character, knowledge and ability; and Section 3312 of Title 5 United States Code, regarding waiver of physical
qualifications for preference eligibles. This form is used to collect medical information about individuals who are incumbents of
positions in the Federal Government which require physical fitness testing and medical examinations, or individuals who have been
selected for such a position contingent upon successful completion of physical fitness testing and medical examinations as a condition
of their employment. The primary use of this information will be to determine the nature of a medical or physical condition that may
affect safe and efficient performance of the work described. Additional potential routine uses of this information include using it to
ensure fair and consistent treatment of employees and job applicants, to adjudicate requests to pass over preference eligibles, or to
adjudicate claims of discrimination under the Rehabilitation Act of 1973, as amended. Completion of this form is voluntary; however,
failure to complete the form may result in no further consideration of an applicant, or a determination that an employee is no longer
qualified for his or her position. In addition, incomplete, misleading, or untruthful information provided on the form may result in delays
in processing the form for employment, termination of employment, or criminal sanction.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this
law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical
information. `Genetic information’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or
family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and
genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or
family member receiving assistive reproductive services.

Public Burden Statement
We estimate an average of two to three hours per response to complete, including the time for reviewing instructions,
getting needed information, and reviewing the completed form. Send comments regarding our estimate or any other
aspect of this form, including suggestions for reducing completion time, to the U.S. Office of Personnel Management
(OPM), Employee Services, Recruitment and Hiring, Hiring Policy, Attn: OMB Number (3206-0250), 1900 E Street, NW,
Washington, D.C. 20415. The OMB number, 3206-0250, is currently valid. OPM may not collect this information, and
you are not required to respond, unless this number is displayed.

Instructions
There are five parts in this form:
Part A - To be completed by applicant or employee. Signature of the applicant or employee certifies that the information provided is
complete and accurate; and that the applicant or employee consents to the release of the examination results to the
employing agency.
Part B - To be completed by the appointing officer before the medical examination: identifies the purpose of the examination; the
position title, series and grade; generally describes the position; and shows the specific functional requirements and
environmental factors that the work requires.
Part C - To be completed and signed by the examining physician, and returned to the employing agency in the pre-paid/pre-addressed
“Confidential-Medical” envelope provided. Access to protected health information may be restricted to the agency medical
officer in accordance with existing and applicable legal requirements.
Part D - To be completed by the agency medical officer who reviews the examination results and recommends action.Upon completion
of Part D, an agency medical officer forwards Parts A, B, D and E to the agency human resources officer. A copy of the entire
form, to include Part C, is retained in the medical record.
Part E - To be completed by the agency human resources officer in order to document the personnel action that is rendered.
If the examining physician/physician assistant/nurse practitioner or reviewing agency medical officer requires additional
space, he/she may add a page titled “See attached continuation with heading 'OF-178 Attachment: Worker Name _____;
Date: _____'" , and create the attachment.
U.S. Office of Personnel Management
Section 3301 of Title 5 United States Code
Title 5 CFR 339
For Local Reproduction Only

Page 1 of 7

Optional Form 178
April 2012
Formerly SF 78
Previous editions not useable

CERTIFICATE OF MEDICAL EXAMINATION

To be given to the individual
examined with a pre-addressed
envelope marked
“Confidential - Medical”.

Form Approved
OMB No. 3206 - 0250

U.S. OFFICE OF PERSONNEL MANAGEMENT

Part A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE
1. Name (Last, First, Middle Initial)

2. Federal Employee Number

3. Sex

4. Birth Date (month, day, year)
Male

Female
5. Do you have any medical disorder or physical impairment which may interfere in any way with the full performance of duties shown in
Part B, No. 3?
Yes

No

(If your answer is YES, explain in writing below, and verbally explain to the physician performing the examination)

6. Address (including City, State, Zip Code)

7. E-mail Address

8. Telephone Numbers (with Area Code)

9. Applicant or Employee Consent and Certification

I certify that all of the information I have provided on this form is complete and accurate to the best of my knowledge, and that submitting
information that is incomplete, misleading, or untruthful may result in termination, criminal sanctions, or delays in processing this form for
employment. Furthermore, consistent with the Privacy Act Statement, I authorize the release to my employing agency of all information
contained on this examination form and all other forms generated as a direct result of my examination.
10. Signature (Do not print)

11. Date (month, day, year)

Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER
1. Purpose of examination

2. Position Title, Series, and Grade

Pre-placement
Other (Specify)_____________________________
3. Brief description of what the position requires the employee to do.

U.S. Office of Personnel Management
Section 3301 of Title 5 United States Code
Title 5 CFR 339
For Local Reproduction Only
Name

Page 2 of 7
Last 4 digits of Social Security Number

Optional Form 178
April 2012
Formerly SF 78
Previous editions not useable
Date

To be given to the individual
examined with a pre-addressed
envelope marked
“Confidential - Medical”.

CERTIFICATE OF MEDICAL EXAMINATION

Form Approved
OMB No. 3206 - 0250

U.S. OFFICE OF PERSONNEL MANAGEMENT

Part B. CONTINUED - TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER
4. Check the box for each functional requirement in section 4a and each environmental factor in section 4b essential to the duties of this
position. List any additional essential factors in the blank spaces. Provide complete reference to applicable medical standards and
requirements in Block 4a and ensure the examining physician/physician assistant/nurse practitioner has immediate and complete
access to these materials when performing this assessment. If the position involves law enforcement, air traffic control, or firefighting,
attach the specific medical standards for the information of the examining physician.
4a. Functional Requirements
Heavy lifting, 45 pounds and over

Repeated bending (______ hours)

Both eyes required

Moderate lifting, 15-44 pounds

Climbing, legs only (______ hours)

Depth perception

Light lifting, under 15 pounds

Climbing, use of legs and arms

Ability to distinguish basic colors

Heavy carrying, 45 pounds and over

Both legs required

Ability to distinguish shades of colors

Moderate carrying, 15-44 pounds

Operation of crane, truck, tractor, or motor
vehicle

Hearing (aid may be permitted)

Light carrying, under 15 pounds
Straight pulling (_____ hours)
Pulling hand over hand (_____ hours)
Pushing (_____ hours)
Reaching above shoulder
Use of fingers
Both hands required
Walking (______ hours)
Standing (______ hours)
Crawling (______ hours)

Ability for rapid mental and muscular
coordination simultaneously
Ability to use and desirability of using
firearms
Near vision correctable at 13” to 16”
to Jaeger 1 to 4
Far vision correctable in one eye to 20/20
and to 20/40 in the other
Specific visual requirement (specify)
______________________________

Hearing without aid
Specific hearing requirements (specify)
Other (specify)
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________

Kneeling (______ hours)

4b. Environmental Factors
Outside

Electrical energy

Working alone

Outside and inside

Slippery or uneven walking surfaces

Protracted or irregular hours of work

Excessive heat

Working around machinery with moving parts

Other (specify)

Excessive cold

Working around moving objects or vehicles

________________________________

Excessive humidity

Working on ladders or scaffolding

________________________________

Excessive dampness or chilling

Working below ground

________________________________

Dry atmospheric conditions

Unusual fatigue factors (specify)

________________________________

Excessive noise, intermittent

______________________________

________________________________

Constant noise

Working with hands in water

________________________________

Dust

Explosives

________________________________

Silica, asbestos, etc.

Vibration

________________________________

Fumes, smoke, or gases

Working closely with others

________________________________

Solvents (degreasing agents)
Grease and oils
Radiant energy

U.S. Office of Personnel Management
Section 3301 of Title 5 United States Code
Title 5 CFR 339
For Local Reproduction Only
Name

Page 3 of 7
Last 4 digits of Social Security Number

Optional Form 178
April 2012
Formerly SF 78
Previous editions not useable
Date

To be given to the individual
examined with a pre-addressed
envelope marked
“Confidential - Medical”.

CERTIFICATE OF MEDICAL EXAMINATION

Form Approved
OMB No. 3206 - 0250

U.S. OFFICE OF PERSONNEL MANAGEMENT

Part C. TO BE COMPLETED BY EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER. Final
examination results must be reviewed and certified by the Agency Medical Officer.
NOTE TO EXAMINING PHYSICIAN: The person you are about to examine will have to cope with the functional requirements and
environmental factors checked in Part 4 of this form. Please take these, and the brief description of the job duties, into consideration as
you make your examination and report your findings and conclusions.
1. Height ________ Feet,

________ Inches.

Weight: ________ Pounds.

2. Eyes:

20

20

20

20

a. Distant vision (Snellen): without corrective lenses: right ____ left ____ ; with corrective lenses, if worn; right ____ left ____
b. Depth perception

Type of test: _____________________________
___________ Seconds of Arc
Number correct: _____ of _____ tested
Interpretation

c. Peripheral vision

Normal

Abnormal

Right Nasal ______ degrees

Temporal ______ degrees

Left Nasal ______ degrees

Temporal ______ degrees

d. What is the longest and shortest distance at which the following specimen of Jaeger No. 2 type can be read by the applicant?
Test each eye separately.
without corrective lenses:

Jaeger No. 2 Type
The President may (1) prescribe such regulations for the admission of
individuals into the civil service in the executive
branch as will best promote the efficiency of that
service; (2) ascertain the fitness of applicants as to
age, health, character, knowledge, and ability for the
employment sought; and (3) appoint and prescribe the
duties of individuals to make inquiries for the purpose
of this section.
(Title 5 U.S. Code 3301)

e. Color vision: Is color vision normal by Ishihara or
other color plate test?

with corrective lenses, if used:

L ______in. to _____ in.

L _____ in. to _____ in.

R______ in. to _____ in.

R _____ in. to_____ in.

Yes

No

Yes

No

Yes

No

If not, can applicant pass lantern test?
Can see red/green/yellow?

U.S. Office of Personnel Management
Section 3301 of Title 5 United States Code
Title 5 CFR 339
For Local Reproduction Only
Name

Page 4 of 7
Last 4 digits of Social Security Number

Optional Form 178
April 2012
Formerly SF 78
Previous editions not useable
Date

To be given to the individual
examined with a pre-addressed
envelope marked
“Confidential - Medical”.

CERTIFICATE OF MEDICAL EXAMINATION
U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved
OMB No. 3206 - 0250

Part C. TO BE COMPLETED BY EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER. Final
examination results must be reviewed and certified by the Agency Medical Officer
3. Ears: (Include certified audiogram results with the examination package).
Right Ear _____ ;
20 ft.

Left Ear _____
20 ft.

4. Other Findings: Describe any abnormality (including diseases, scars, and disfigurations). Include brief pertinent history. If normal,
so indicate.
a.

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

b.

Abdomen

c.

Head and back (including face, hair, and scalp)

d.

Peripheral blood vessels

e.

Speech (note any malfunction)

f.

Extremities (including strength, range of motion)

g.

Skin and lymph nodes (including thyroid gland)

h.

Urinalysis (if indicated)
SP. Gr. __________

Sugar __________

Blood __________

Albumen __________

Casts __________

Pus

i.

Respiratory tract (X-ray if indicated)

j.

Heart (size, rate, rhythm, function)

__________

Blood pressure ______________
Pulse _______________
EKG (if indicated)
k.

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

l.

Neurological (including reflexes, sensation) and mental health

U.S. Office of Personnel Management
Section 3301 of Title 5 United States Code
Title 5 CFR 339
For Local Reproduction Only
Name

Page 5 of 7
Last 4 digits of Social Security Number

Optional Form 178
April 2012
Formerly SF 78
Previous editions not useable
Date

To be given to the individual
examined with a pre-addressed
envelope marked
“Confidential - Medical”.

CERTIFICATE OF MEDICAL EXAMINATION
U.S. OFFICE OF PERSONNEL MANAGEMENT

Form Approved
OMB No. 3206 - 0250

Part C. TO BE COMPLETED BY EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER. Final
examination results must be reviewed and certified by the Agency Medical Officer
5. Conclusions: Summarize below any medical findings that in your opinion, would limit this person's ability to perform these job duties or
make them a hazard to themselves or others. If none, so indicate.
No limiting conditions for this job
Limiting conditions as follows:

6. Examining Physician's Name

7. E-Mail Address

8. Address (Including Street, City, State and ZIP Code)

9. Telephone Number

10. Signature of Examining Physician

11. Date (Month, Day, Year)

IMPORTANT: After signing, return the entire form intact in the pre-addressed “Confidential-Medical” envelope which the person you
examined gave you.

U.S. Office of Personnel Management
Section 3301 of Title 5 United States Code
Title 5 CFR 339
For Local Reproduction Only
Name

Page 6 of 7
Last 4 digits of Social Security Number

Optional Form 178
April 2012
Formerly SF 78
Previous editions not useable
Date

To be given to the individual
examined with a pre-addressed
envelope marked
“Confidential - Medical”.

CERTIFICATE OF MEDICAL EXAMINATION

Form Approved
OMB No. 3206 - 0250

U.S. OFFICE OF PERSONNEL MANAGEMENT

FOR AGENCY USE ONLY

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.
1. Recommendation:
Medically Qualified

Medically Qualified if restrictions accommodated (list restrictions)

Medically Disqualified

2. Agency Medical Officer's Name

3. E-Mail Address

4. Address (Including Street, City, State and ZIP Code)

5. Telephone Number

6. Signature of Agency Medical Officer

7. Date (Month, Day, Year)

FOR AGENCY USE ONLY

Part E. TO BE COMPLETED BY AGENCY HUMAN RESOURCES OFFICER
1. Action Taken:
Hired or Retained
Non-Selected for Appointment, or Eligibility Objected To
Action Taken to Separate
2. Agency Human Resources Officer's Name

3. E-Mail Address

4. Address (Including Street, City, State and ZIP Code)

5. Telephone Number

6. Signature of Agency Human Resources Officer

7. Date (Month, Day, Year)

Print Form

U.S. Office of Personnel Management
Section 3301 of Title 5 United States Code
Title 5 CFR 339
For Local Reproduction Only
Name

Save Form

Page 7 of 7
Last 4 digits of Social Security Number

Clear Form

Optional Form 178
April 2012
Formerly SF 78
Previous editions not useable
Date