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GP69 Medical Form

This document is a medical examination form for candidates seeking temporary, contract, or permanent employment with the Kenyan government. It consists of two parts: Part 1 is completed by the ministry or department sending the candidate for examination, providing their name and address as well as the candidate's name. Part 2 is completed by the examining medical officer, certifying whether the candidate is fit or unfit for the intended service based on their medical examination. It also includes notes on completing the form and questions for the candidate to answer regarding their medical history.

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Justina wanjiru
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2K views2 pages

GP69 Medical Form

This document is a medical examination form for candidates seeking temporary, contract, or permanent employment with the Kenyan government. It consists of two parts: Part 1 is completed by the ministry or department sending the candidate for examination, providing their name and address as well as the candidate's name. Part 2 is completed by the examining medical officer, certifying whether the candidate is fit or unfit for the intended service based on their medical examination. It also includes notes on completing the form and questions for the candidate to answer regarding their medical history.

Uploaded by

Justina wanjiru
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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(To be completed in DUPLICATE)

REPUBLIC OF KENYA G.P.69

PART 1

(Name and address of Ministry/Department)

……………………………………………………………………

……………………………………………………………………

TO: The Medical Officer I/C………………………………………… ……………………………………………………………………..

Name: *Mr./Miss/Mrs……...……………………………………………………………………is sent herewith for medical


examination as a candidate for *temporary/Contract /Permanent employment/fitness to extend tour by
………………………………………………………….Months (C.O.R. N20 (1) as …………………………………………………in this
*Ministry/Department

………..…………………………………………………………(signature)

……………………………………………………………….(Designation)

PART 2

CERTIFICATE OF MEDICAL EXAMINATION

I HEREBY CERTIFY that I have this day examined the above named candidate and that in my opinion
*he/she is *fit/unfit for *temporary/contract/permanent service/extension of tour by ………………………

Months (C.O.R. N20 (1) as………………………………………………………… in the Kenya Government


Administration.

…………………………………………………….Station ………………………………………………………………………………….

…………………………………………………….20…………. Medical Officer.

NOTES

Part 1 of the form to be completed in duplicate by the officer sending the candidate for examination.

Part 2 of the form to be completed by the Medical Officer, who will return one copy to the
Ministry/Department which sent the candidate.

Particulars on reverse to be filled in by candidate before appearing for medical Examination

*Delete whichever is applicable.


Candidates full name (in BLOCK letters)……………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………

The following questions to be answered by the candidates.

1. Have you ever been an in-patient in hospital or nursing home suffering from any disease or
injury? If so, give dates, state nature of disease or injury, which hospital or nursing home.
Name of Doctor (s) who treated you and whether an operation was performed ………………..
2.
……………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………

3. Apart from above, have you ever received medical treatment for any serious diseases or injury?
If so give particulars
……………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………

……………………………………………………………..20……………………………………..
……………………………………………………………………………………………………….
Signature of Candidate.

______
GOK.

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