ANNEX – C

A.O. No. 2013-0006

SPECIFICATIONS OF AND INSTRUCTIONS ON HOW TO ACCOMPLISH

ANNEX – C “MEDICAL CERTIFICATE FOR LANDBASED
OVERSEAS WORKERS”

1. Use only size A4 bond paper with a MINIMUM of substance 20.

2. Use only one (1) sheet of bond paper with the following back to
back information:
a. Front page – MEDICAL CERTIFICATE FOR LANDBASED
OVERSEAS WORKERS;
b. Back page – contains the IMPORTANT INTEGRAL NOTES.
3. Use only English language.
4. Use only black ink.
5. Use only white background.
6. The applicant’s photo shall be digitized.
7. The Official Stamp or Clinic Logo may be in color but the clinic
name and information must be in black.
8. Security features are allowed.
9. Kindly put a check mark (✓) on the appropriate box and enter
all data called for. Do not leave any item blank.
10. The applicant shall affix his/her signature in the presence of the
examining physician.
11. The signature of the examining physician shall be original and/or
in accordance with the E-Commerce Law.

Approved by:

(sgn’d) ATTY. NICOLAS B. LUTERO III, CESO III

Assistant Secretary
Department of Health

NAME OF CLINIC
DOH ACCREDITATION NUMBER
Clinic Address
Clinic Contact Information
Email Address

MEDICAL CERTIFICATE FOR LANDBASED OVERSEAS WORKERS

 ANNEX – C
A.O. No. 2013-0006
Approved and authorized by the Department Of Health (DOH)

SURNAME/LAST NAME: GIVEN NAME: MIDDLE NAME

AGE: DATE OF BIRTH: PLACE OF BIRTH: NATIONALITY:

DAY MONTH YEAR

GENDER: MALE FEMALE CIVIL STATUS: SINGLE MARRIED RELIGION:

ADDRESS:

PASSPORT NUMBER: COUNTRY OF DESTINATION:

POSITION APPLIED FOR: EMPLOYER/COMPANY/RECRUITMENT AGENCY (IF APPLICABLE):

SATISFACTORY HEARING? YES NO

SATISFACTORY SIGHT? YES NO

SATISFACTORY COLOR VISION? (WHEN REQUIRED) YES NO

SATISFACTORY PSYCHOLOGICAL TEST? YES NO

IS APPLICANT SUFFERING FROM ANY MEDICAL CONDITION LIKELY TO BE AGGRAVATED BY LANDBASED OVERSEAS WORK OR TO RENDER THE APPLICANT
UNFIT FOR SUCH SERVICE OR TO ENDANGER THE HEALTH OF OTHER PERSONS?
YES NO

THIS IS TO CERTIFY THAT A MEDICAL AND PHYSICAL EXAMINATION WAS GIVEN TO:
PHOTO
______________________________________________
(MUG SHOT) (NAME OF APPPLICANT)

RESULT:
PASSPORT SIZE
FIT UNFIT

___________________________________________________
Name and Signature of Examining/Authorized Physician

Date of Examination:__________________________________
OFFICIAL STAMP

Approved by:

___________________________________________________
Medical Director

I HAVE READ AND UNDERSTOOD THE CONTENTS OF THE ABOVE AND THE INTEGRAL NOTES HEREOF.

APPLICANT’S NAME AND SIGNATURE: ________________________________________________________________ DATE: __________________

(THIS SIGNATURE SHOULD BE AFFIXED IN THE PRESENCE OF THE EXAMINING PHYSICIAN)
DATE OF ISSUANCE OF PEME CERTIFICATE: DATE OF EXPIRATION OF PEME CERTIFICATE:
(Filling out this field is not mandatory.)
DAY MONTH YEAR DAY MONTH YEAR
DOH-PEME-LB
Revision:00
05/21/2013
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IMPORTANT INTEGRAL NOTES

 ANNEX – C
A.O. No. 2013-0006
1. Details of any medical condition identified or test results other than those listed
herein are not recorded in this Certificate.

2. A Medical Examination Report (MER) containing the medical history, clinical findings
and other diagnostic tests and results of the applicant is contained in a separate
document in compliance with DOH Guidelines and the host country/ principal’s
requirements.

3. This certificate is neither a certificate of general health nor a certification of the

absence of illness. It is a confirmation that the applicant is expected to be able to
meet the minimum requirements for performing his/her duties specific to their job
overseas safely and effectively.

4. This medical certificate shall be valid for a maximum period of ninety (90) days prior
to deployment, subject to physician’s recommendations and/or principal’s
requirements.

5. An applicant who has been refused a medical certificate or has had a limitation
imposed on his/her ability to work, shall be given the opportunity to have an
additional examination by another medical practitioner or medical referee who is
independent of the principal or of any organization.

DOH-PEME-LB
Revision:00
05/21/2013
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