Optional Form 178 – Fill Out and Use This PDF

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.

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. `Genetic information’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

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		Optional Form 178
Section 3301 of Title 5 United States Code		April 2012
Title 5 CFR 339		Formerly SF 78
For Local Reproduction Only	Page 1 of 7	Previous editions not useable

Part A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE

1. Name (Last, First, Middle Initial)

2. Federal Employee Number

3. Sex

4. Birth Date (month, day, year)

Male

Female

5.Do you have any medical disorder or physical impairment which may interfere in any way with the full performance of duties shown in Part B, No. 3?

Yes No

(If your answer is YES, explain in writing below, and verbally explain to the physician performing the examination)

6. Address (including City, State, Zip Code)

9. Applicant or Employee Consent and Certification

I certify that all of the information I have provided on this form is complete and accurate to the best of my knowledge, and that submitting information that is incomplete, misleading, or untruthful may result in termination, criminal sanctions, or delays in processing this form for employment. Furthermore, consistent with the Privacy Act Statement, I authorize the release to my employing agency of all information contained on this examination form and all other forms generated as a direct result of my examination.

Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

3. Brief description of what the position requires the employee to do.

U.S. Office of Personnel Management		Optional Form 178
Section 3301 of Title 5 United States Code		April 2012
Title 5 CFR 339		Formerly SF 78
For Local Reproduction Only	Page 2 of 7	Previous editions not useable

Part B. CONTINUED - TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

4.Check the box for each functional requirement in section 4a and each environmental factor in section 4b essential to the duties of this position. List any additional essential factors in the blank spaces. Provide complete reference to applicable medical standards and requirements in Block 4a and ensure the examining physician/physician assistant/nurse practitioner has immediate and complete access to these materials when performing this assessment. If the position involves law enforcement, air traffic control, or firefighting, attach the specific medical standards for the information of the examining physician.

4b. ENVIRONMENTAL Factors

U.S. Office of Personnel Management		Optional Form 178
Section 3301 of Title 5 United States Code		April 2012
Title 5 CFR 339		Formerly SF 78
For Local Reproduction Only	Page 3 of 7	Previous editions not useable

Part C. TO BE COMPLETED BY EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER. Final

examination results must be reviewed and certified by the Agency Medical Officer.

NOTE TO EXAMINING PHYSICIAN: The person you are about to examine will have to cope with the functional requirements and environmental factors checked in Part 4 of this form. Please take these, and the brief description of the job duties, into consideration as you make your examination and report your findings and conclusions.

1.	Height ________ Feet, ________ Inches.	Weight: ________ Pounds.
2.	Eyes:
		20	20	20	20
a.	Distant vision (Snellen): without corrective lenses: right ____ left		____ ; with corrective lenses, if worn; right ____		left ____
b.	Depth perception	Type of test: _____________________________
		___________ Seconds of Arc
		Number correct: _____ of _____ tested
		Interpretation	Normal	Abnormal
c.	Peripheral vision	Right Nasal ______ degrees		Temporal ______ degrees
		Left Nasal ______ degrees		Temporal ______ degrees

d. What is the longest and shortest distance at which the following specimen of Jaeger No. 2 type can be read by the applicant?

U.S. Office of Personnel Management		Optional Form 178
Section 3301 of Title 5 United States Code		April 2012
Title 5 CFR 339		Formerly SF 78
For Local Reproduction Only	Page 4 of 7	Previous editions not useable

Part C. TO BE COMPLETED BY EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER. Final

examination results must be reviewed and certified by the Agency Medical Officer

3. Ears: (Include certified audiogram results with the examination package).

Right Ear _____ ;	Left Ear _____
20 ft.	20 ft.

4.Other Findings: Describe any abnormality (including diseases, scars, and disfigurations). Include brief pertinent history. If normal, so indicate.

a.Eyes, ears, nose, and throat (including tooth and oral hygiene)

b.Abdomen

c.Head and back (including face, hair, and scalp)

d.Peripheral blood vessels

e.Speech (note any malfunction)

f.Extremities (including strength, range of motion)

g.Skin and lymph nodes (including thyroid gland)

h.Urinalysis (if indicated)

SP. Gr. __________	Sugar __________	Blood __________
Albumen __________	Casts __________	Pus __________

i.Respiratory tract (X-ray if indicated)

j.Heart (size, rate, rhythm, function)

Blood pressure ______________

Pulse _______________

EKG (if indicated)

k.Back (special consideration for positions involving heavy lifting and other strenuous duties)

l.Neurological (including reflexes, sensation) and mental health

U.S. Office of Personnel Management		Optional Form 178
Section 3301 of Title 5 United States Code		April 2012
Title 5 CFR 339		Formerly SF 78
For Local Reproduction Only	Page 5 of 7	Previous editions not useable

Part C. TO BE COMPLETED BY EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER. Final

examination results must be reviewed and certified by the Agency Medical Officer

5.Conclusions: Summarize below any medical findings that in your opinion, would limit this person's ability to perform these job duties or make them a hazard to themselves or others. If none, so indicate.

No limiting conditions for this job

Limiting conditions as follows:

6.	Examining Physician's Name	7.	E-Mail Address
8.	Address (Including Street, City, State and ZIP Code)	9.	Telephone Number
10.	Signature of Examining Physician	11.	Date (Month, Day, Year)

IMPORTANT: After signing, return the entire form intact in the pre-addressed “Confidential-Medical” envelope which the person you examined gave you.

U.S. Office of Personnel Management		Optional Form 178
Section 3301 of Title 5 United States Code		April 2012
Title 5 CFR 339		Formerly SF 78
For Local Reproduction Only	Page 6 of 7	Previous editions not useable

FOR AGENCY USE ONLY

Part D. TO BE COMPLETED BY AGENCY MEDICAL OFFICER (if one is available)

NOTE: Review the attached certificate of medical examination and make your recommendations in item 1 below.

1. Recommendation:

Medically Qualified

Medically Qualified if restrictions accommodated (list restrictions)

Medically Disqualified

FOR AGENCY USE ONLY

Part E. TO BE COMPLETED BY AGENCY HUMAN RESOURCES OFFICER

1. Action Taken:

Hired or Retained

Non-Selected for Appointment, or Eligibility Objected To

Action Taken to Separate

2. Agency Human Resources Officer's Name

3. E-Mail Address

U.S. Office of Personnel Management		Optional Form 178
Section 3301 of Title 5 United States Code		April 2012
Title 5 CFR 339		Formerly SF 78
For Local Reproduction Only	Page 7 of 7	Previous editions not useable