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The document outlines the requirements for a Certificate of Physical Fitness for candidates applying to various services in Telangana. It specifies that the certificate must be signed by a qualified Medical Officer and includes detailed medical history and examination results. Candidates must also declare their health status and family medical history, with consequences for providing false information.

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6 views

empForm16

The document outlines the requirements for a Certificate of Physical Fitness for candidates applying to various services in Telangana. It specifies that the certificate must be signed by a qualified Medical Officer and includes detailed medical history and examination results. Candidates must also declare their health status and family medical history, with consequences for providing false information.

Uploaded by

bairisolomonraj16
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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CERTIFICATE OF PHYSICAL FITNESS

(For posts in Telangana Engineering Services, the Telangana Judicial Ministerial Service and etc.,)

*******

This form is to be used by every candidate who is required by


Telangana Public Service Commission to produce a certificate of Physical
Fitness. It must be signed by a commissioned Medical Officer or a Civil
Medical Officer of rank not lower than that of Civil Surgeon or a District
Medical Officer employed under Telangana Government.

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Note: A candidate who resides outside the Telangana State and who is
unable to produce the certificate from a Medical Officer employed in the
Telangana State and produce it from a Medical Officer of corresponding
rank outside the Telangana. Such certificate should contain the following
Particulars:-

1. The state under which the Medical Officer is employed and the
name of the Institution in which he is employed and his rank.

2. Register Number of the certifying Medical Officer in the Register


in which his name has been registered.

3. The Official stamp of the Institution in which the certifying


Medical Officer is employed.

The Certificate so produced will be subject to acceptance after


scrutiny by the Director of Medical Services, Telangana.

Name and rank of Officer granting the certificate.

I do hereby certify that I have examined(full Name )……………………..

a candidate for employment under the Government of Telangana in


the………………………………… service as…………………………… and cannot discover
that he has any diseases communicable or otherwise constitutional
affection or bodily infirmity except that his weight is in the standards
prescribed, or except………………………………………I do not/ do consider this a
disqualification for the employment he seeks:
His age is according to his own statement ………………. Years and by
appearance about……………....I also certify that he has marks of small pox
/ vaccination Chest Measurements in

Inches on Full Inspiration.

Height Full expiration.

Weight in Lbs. Difference ( Expansion)

His vision is normal Inches.

Hypermetropic
(here enter the degree of defect and the strength or correction glass)

Myopic . . . …………………………………………………………………………………………....
(here enter the degree of defect and the strength of correction glasses)

Hearing is normal, defective


(Much or slight)
Urine-Does Chemical examination,
(show (I) albument (ii) Sugar,
State Specific gravity.
Personal marks ( atleast two should be mentioned)

1.

2.

Station: Signature:

Date: Rank:
Designation.
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The candidate must make the statement required below prior to his
medical examination and must assign the declaration appended there to
in the presence of the Medical Officer. His attention is specially directed to
the warning contained in the note below.

1. State your name in full :

2. State your age and birth Place :


3(a) Have you ever had smallpox
intermittent or any other fever
enlargement or supportation of glands, :
spitting of blood, Asthma, Inflation of lungs,
heart disease fainting attacks, Rheumatism :
appendicitis?
(or)

(b) Any other disease or accident requiring


confinement to be and medical or surgical :
treatment?

(c) Suffered from any illness would or injuries,


sustained while on active service with his :
majesty forces, during the war which began
in 1914 ?

4. When were you last vaccinated? :

5. Have you or any of your near relations been


affected with consumption scrofuels gout, :
Asthma, Fits, Epilepsy or identify ?

6. Have you suffered from any from nervousness :


due to over work or any other causes ?

7.Have you been examined and declared unfit :


For Govt. service by a Medical Officer/ Medical
Board within the last three years.

8. (to be filled in only in the case of candidates for :


subordinate concerning your family)
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Father’s age father’s age No.of brothers No.of brothers


of living and at death and living, their dead, their age
etc.,
State of health cause of death age of state of and cause of
Health death.

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Mother’s age Mother’s age No.of Sisters No.of Sisters
of living and at death and living, their dead, their age
etc.,
State of health cause of death age of state of and cause of
Health death.
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I declare all the above, answers to be, to the best of my belief, true
and correct.

I also solemnly affirm that I have not received a disability


certificate/ pension on account of any diseased or other conditions.

Candidate's signature.

Signature of Medical Officer:

Note:-

The candidate will be held responsible for the accuracy of the above
statement by willfully suppressing any information he will incur the risk of
loosing the appointment and if appointed, or forfeiting all claims to
superannuation allowance or gratuity.

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