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It includes the Privacy Act Statement and Public Burden Statement, outlines five form parts (A through E) with responsibilities for the applicant/employee, appointing officer, examining physician, agency medical officer, and agency human resources officer, and specifies consent, confidentiality, and use of protected health information. 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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 delaysin processing the form for employment, termination of employment, or criminal sanction. |\n| Public Burden Statement |\n| 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. |\n| Instructions |\n| There are five parts in this form:\u003Cbr>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.\u003Cbr>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.\u003Cbr>Part C-To be completed and signed by the examining physician, and returned to the employing agency in the pre-paid/preaddressed “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.\u003Cbr>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.\u003Cbr>Part E-To be completed by the agency human resources officer in order to document the personnel action that is rendered. If the exami","cbCaiuHQQel6WR6T","https://ap.wps.com/l/cbCaiuHQQel6WR6T","pdf",1484182,"English","# Privacy Act Statement\n# Public Burden Statement\n# Instructions\n# Part A: Applicant or Employee\n# Part B: Appointing Officer\n# Part C: Examining Physician\n# Part D: Agency Medical Officer\n# Part E: Agency Human Resources Officer","[{\"question\":\"What is the purpose of the OF-178 certificate of medical examination?\",\"answer\":\"It collects medical information to help determine a federal applicant’s or employee’s fitness for employment, including medical or physical conditions that may affect safe and efficient performance.\"},{\"question\":\"Who completes each part of the form (Part A through Part E)?\",\"answer\":\"Part A is completed by the applicant or employee; Part B by the appointing officer; Part C by the examining physician; Part D by the agency medical officer; and Part E by the agency human resources officer.\"},{\"question\":\"What should the applicant/employee do if they answer “Yes” to having a medical disorder or physical impairment?\",\"answer\":\"They must explain in writing below and also verbally explain to the physician performing the examination.\"}]","OF-178 - Certificate of Medical Examination - Instructions and Parts A-E | PDF",1789748718,18]