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.
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
A
pril 2012
Formerly SF 78
Previous editions not useable