Certificate of Medical Examination - U. S. Office of Personnel Management
CERTIFICATE OF MEDICAL EXAMINATION
U.S. OFFICE OF PERSONNEL MANAGEMENT
Form Approved
OMB No. 3206 - 0250
To be given to the individual
examined with a pre-addressed
envelope marked
“Confidential - Medical”.
U.S. Office of Personnel Management
Section 3301 of Title 5 United States Code
Title 5 CFR 339
For Local Reproduction Only
Optional Form 178
July 2009
Formerly SF 78
Previous editions not useable
Page 1 of 8
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.
Part D - To be completed by the agency medical officer who reviews the examination results and recommends action.
Part E - To be completed by the agency human resources officer in order to document the personnel action that is
rendered.
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), Strategic Human Resources Policy, Medical Policy and Programs Division, 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.
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