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| Question | Answer |
|---|---|
| Form Name | Csc Form No 41 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | form 41 for maternity leave, csc form 41 medical certificate 2020, csc form 41, form 41 |
PHILIPPINE CIVIL SERVICE
MEDICAL CERTIFICATE
CSC FORM – 41
I hereby waive my rights and privileges pertaining to professional confidence between physician and patient, and the physician accomplishing this form is authorized to answer in detail all questions contained here.
_____________________________
(Signature of Patient)
N.B. – (Attending physician should fill in the blanks below, every detail should be answered to avoid delay in actions on application for leave submitted by the patient.)
_______________________________ of the Department of Education, Culture and
(Name of Patient)
Sports having made application for leave of absence on account of illness, I do hereby certify that I was the applicant’s actual attending physician from
_____________________ , ____ to ___________________, ____, inclusive and from
my professional knowledge of the case the following statements submitted, as contemplated by the provisions of Section 6 of Civil Service Rule XVI.
Name of Disease or Disability:___________________________________
Nature of Disease or Disability: __________________________________
ETHIOLOGY – (Under the heading in addition to giving fully the ethiology of the (disease or disability, the physician must either state in the language of
(the Executive Order: “There are no indications whatsoever that the (disease named was due to immoral or vicious habits” or give the
indications.)
HISTORY: ______________________________________________________________
________________________________________________________________________
DESCRIPTION:__________________________________________________________
________________________________________________________________________
A laboratory test examination was ________________made in this case.
The applicant was confined to (his/her house/hospital) from
__________________, _____to ____________________, ________
===============================================================
I hereby certify that the above statement is complete and true in every detail and that in consequence of the disease or the disability above specified the applicant was ill and unable to be on duty on account of illness _______________________, ______ to
_____________________, ______, inclusive, and that his/her claim is meritorious.
(Signature) __________________________
(P. O. Address)_______________________
___________________________________
(If this certificate is executed in the Philippines, affix here one DOCUMENTARY STAMP)