Form MRP Form 5-R MRP Form 5-R Self-Certification Medical Statement

(MRP Directive 4339.1 Attachment)
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a valid OMB control number. The valid OMB control numbers for this information collection is 0579-0196. The time required
to complete this information collection is estimated to average .167 hours per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

OMB Approved
0579-0196
EXP: XX/XXXX

SELF-CERTIFICATION
MEDICAL STATEMENT

UNITED STATES DEPARTMENT OF AGRICULTURE
MARKETING AND REGULATORY PROGRAMS

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. 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
DATE OF BIRTH (Month, Day, Year)

APPLICANT NAME (Last, First, Middle)
ADDRESS (Number, Street, City, State, ZIP)

SOCIAL SECURITY NUMBER

TITLE OF POSITION APPLIED FOR

SELF CERTIFICATION QUESTIONNAIRE
SECTION A - PHYSICAL LIMITATIONS

SECTION C - ENVIRONMENTAL ENDURANCE FACTORS

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

YES NO
1. Can you read small newspaper print (corrective lenses are permitted)?

Some positions may involve unusual working conditions or working outdoors. Answer
each item “YES” or “NO” by placing an “X” in the proper box to the right. If you answer
YES NO
“NO” to any item, give additional details in Section D.

Can you work under the following conditions:

2. Can you distinguish basic colors (red, green, blue)?

27. Outdoors and indoors?

3. Can you distinguish shades of colors?

28. Severe heat?

4. Can you distinguish normal tastes and smells?

29. Severe cold?

5. Can you communicate effectively and independently by telephone?

30. Severe humidity?

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

31. Severe dampness or chilling?
32. Dry atmospheric conditions?

6. Sitting for long periods of time?

33. Severe noise?

7. Standing for long periods of time?

34. Constant noise?

8. Some walking on flat surfaces, slight inclines, and occasionally
climbing stairs?

35. Dusty atmosphere?

9. Frequent walking and/or climbing stairs or steep inclines?

36. Some exposure to fumes, smoke, and/or gasses?

10. Continuous pulling ( _____ hours)?

37. Some (incidental) contact with solvents, greases, and/or oils?

11. Occasional pushing and pulling?

38. Some contact with laboratory substances and/or chemicals?

12. Frequent pushing and pulling motions?

39. Working with hands in water?

13. Occasional bending, stooping, and crouching?

40. Occasional walking over rough terrain?

14. Frequent bending, stooping, and crouching?

41. Slippery or uneven walking surfaces?

15. Lifting and carrying under 15 pounds?

42. Around machinery with moving parts?

16. Lifting and carrying 15 to 44 pounds?

43. Around moving objects and/or vehicles?

17. Lifting and carrying 45 pounds or more?

44. Climbing ladders and/or scaffolding?

18. Reaching above shoulders?

45. Working below ground surface?

19. Repeated bending ( _____ hours)?

46. Working alone?

20. Standing ( _____ hours)?

47. Working closely with others?

21. Crawling ( _____ hours)?

48. Protracted or irregular hours of work?

22. Kneeling ( _____ hours)?

49. Commercial air travel?

23. Climbing, use of arms and legs?

50. Rotating shifts?

24. Operating a motor vehicle?

51. Nights?

25. Working under pressure and time constraints?
26. Performing rapid mental and muscular coordination simultaneously?

MRP FORM 5-R
OCT 2017

(Local reproduction authorized.)

SECTION D - ADDITIONAL DETAILS
This space is for detailed answers to Sections A, B, and/or C and any additional information you may wish to provide. Annotate the Item number and description.

ITEM
NUMBER

DESCRIPTION

ITEM
NUMBER

DESCRIPTION

If you need more space, attach additional sheet(s)

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 IS 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, the Appointing Officer believes the applicant is physically unable to do the job or would create a
hazard to him or herself or others, the Appointing Officer may require the applicant to undergo a medical examination. The examination may not be required solely on the
basis of the applicant's age, sex, or other non-job related factor. For positions having unusual sight or hearing requirements, an appropriate specialized examination may be
required at the Federal Government’s expense.
THE AGENCY OFFICIAL WILL:
1. Complete the field “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 indicated by the applicant's replies. A Federal Medical Officer should be consulted when indicated
by detailed replies.
4. In accordance with 5 CFR 339.306, the Appointing Officer is authorized to medically disqualify a non-preference eligible. If the candidate is a preference eligible, the Office
of Personnel Management (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/she must then submit the entire record (including the SF-78, Certificate of Medical Examination; the MRP Form 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 OPM for a decision.