Of 178 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part A, where you will enter your personal information including your name, federal employee number, sex, and birth date. Ensure all details are accurate.
3. Indicate if you have any medical disorders that may affect your job performance. If yes, provide a detailed explanation for the examining physician.
4. Complete your contact information including address, email, and phone numbers. Finally, sign and date the form to certify the accuracy of your information.
5. In Part B, the appointing officer will fill out details regarding the purpose of the examination and position requirements. Ensure they complete this section before your medical exam.
6. Part C is for the examining physician to document findings. Make sure they return this part in the provided confidential envelope.
7. Parts D and E are completed by agency medical and human resources officers respectively after reviewing the examination results.

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