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Gp-69-Form-Medical-Examination-1 (1)

This document is a medical examination form for candidates seeking employment or an extension of service in the Republic of Kenya. It includes sections for the sending officer to complete and for the medical officer to certify the candidate's fitness for service. Candidates are required to provide personal medical history and details regarding any past treatments or hospitalizations.

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76 views2 pages

Gp-69-Form-Medical-Examination-1 (1)

This document is a medical examination form for candidates seeking employment or an extension of service in the Republic of Kenya. It includes sections for the sending officer to complete and for the medical officer to certify the candidate's fitness for service. Candidates are required to provide personal medical history and details regarding any past treatments or hospitalizations.

Uploaded by

blueivyl872
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)

G.P. 69

REPUBLIC OF KENYA

PART I

(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. N.20 (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 ......................................................................... Medical Officer
…………………..............., 20 ……
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 inapplicable.
Candidate’s full name (in BLOCL letters) ……………………………………………………………………
…………………………………………………………………………………………………………………
The following questions to be answered by the candidate:
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 Apart from above, have you ever received medical treatment for any serious disease or injury? If
so, give particulars.
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………

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

GPK

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