Form Of 345 PDF Details

Form of 345 is a medication used to treat high blood pressure. It comes in the form of a pill, and is typically taken once a day. The dosage may vary depending on your individual needs. Consult with your doctor to find the best dosage for you. Form of 345 can help control blood pressure, and may help reduce your risk of heart attack and stroke. It is important to take this medication as prescribed by your doctor, and to follow any other instructions provided. If you have any questions or concerns, be sure to speak with your doctor.

You'll find it useful to understand the amount of time you will need to fill in this form of 345 and just how long the document is.

QuestionAnswer
Form NameForm Of 345
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesNSN, of 345, 345, OPM

Form Preview Example

OF 345

PHYSICAL FITNESS INQUIRY FOR MOTOR VEHICLE OPERATORS

(11/85)

Office of Personnel Management

FPM Chapter 930 (EF-V1)(PerForm Pro)

1.Name (Last, First, Middle)

2.Date of Birth (Month, Day, Year)

3. Title of Position

4.Home Address (Number, Street or RFD, City, State and Zip Code)

5. Employing Agency

6.Have you ever had or have you now: (Place check at left of each item.)

YES

NO

 

YES

NO

 

 

 

Poor vision in one or both eyes

 

 

Arthritis, rheumatism, swollen or painful joints

 

 

Eye disease

 

 

Loss of hand, arm, foot, or leg

 

 

Poor hearing in one or both ears

 

 

Deformity of hand, arm, foot, or leg

 

 

Diabetes

 

 

Nervous or mental trouble of any kind

 

 

Palpitation, chest pain, or shortness or breath

 

 

Blackouts or epilepsy

 

 

Dizziness or fainting spells

 

 

Sugar or albumin in urine

 

 

Frequent or severe headaches

 

 

Excessive drinking habit (Alcohol)

 

 

High or low blood pressure

 

 

Other serious defects or diseases

 

 

Drug or narcotic habit

 

 

 

7. If your answer is "Yes" to one or more of the above questions, explain fully in this space, indicating date of original condition and current status:

8.(A) Do you wear glasses (or contact lenses) while driving?

(B)Do you wear a hearing aid?

YES

YES

NO

NO

PRIVACY ACT STATEMENT

 

Solicitation of this information is authorized by 40 U.S.C. 491 and 5

Based on the information provided, employees may be referred for a

CFR Part 930 Subpart A, which require OPM to regulate Federal

medical examination before being granted an initial authorization or a

employees use of Government-owned or -leased motor vehicles. It is

renewal. The disclosure of this information is mandatory when an

used to ascertain the physical fitness of Federal employees, whose

employee's job requires driving a Federal motor vehicle and is

jobs require authorization to drive Government-owned or -leased

voluntary otherwise.

However, failure to complete when requested

vehicles. It is also used in the renewal of authorizations for all such

may result in you not being permitted to operate a Government

employees.

vehicle.

 

Certification: I certify that my answers to the above are full and true,

9. Signature

10. Date Signed

and I understand that a willfully false statement or dishonest answer

 

(Month, Day, Year)

 

 

may be grounds for cancellation of my eligibility or my dismissal from

 

 

the service and is punishable by law.

 

 

REVIEW AND CERTIFICATION BY DESIGNATED OFFICIAL

I certify that I have reviewed this physical fitness injury form and other available information regarding the physical condition of the applicant, and that I have made the following determination:

1. There is no information on this form or otherwise available to indicate that the applicant should be referred for physical examination.

2. On the basis of items checked on this form or other information, this applicant must be referred for physical examination before authorized to operate a Government-owned or -leased motor vehicle or current authorization is renewed.

3. Items checked on this form or otherwise available do not warrant referral for medical examination because of the following facts:

Signature of Designated Official

Date Signed

(Month, Day, Year)

50345-101

Reset

NSN: 7540-00-634-4000

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Within the field Solicitation of this information, Based on the information provided, Certification I certify that my, Signature, Date Signed Month Day Year, REVIEW AND CERTIFICATION BY, I certify that I have reviewed, There is no information on this, Items checked on this form or, Signature of Designated Official, Date Signed Month Day Year, and NSN enter the information the platform asks you to do.

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