Framework Service Contract XX/2018/OP/EITPROC Task 2: Annual medical examination/ Health screening examination □ □ Order form reference: Name of EIT/CEPOL staff member: Name of attending doctor: Date and place of examination: Programme performed according to age/gender: Please Gender Age tick Women Up to 40 Women 40 to 45 Women Over 45 Men Up to 40 Men 40 to 45 Men Over 45 IMPORTANT: Only programmes corresponding to the EIT/CEPOL staff member’s age and any other conditions shall be administered and only the respective costs will be reimbursed by the EIT/CEPOL. General result of examination: The medical aptitude of the person is confirmed: APT / NON - APT □ □ Date and signature of attending doctor:
Framework Service Contract XX/2018/OP/EITPROC Task 2: □ Annual medical examination/ □ Health screening examination Order form reference: Name of EIT/CEPOL staff member: Name of attending doctor: Date and place of examination: Programme performed according to age/gender: Please tick Gender Age Women Up to 40 Women 40 to 45 Women Over 45 Men Up to 40 Men 40 to 45 Men Over 45 IMPORTANT: Only programmes corresponding to the EIT/CEPOL staff member’s age and any other conditions shall be administered and only the respective costs will be reimbursed by the EIT/CEPOL. General result of examination: The medical aptitude of the person is confirmed: □ APT / □ NON - APT Date and signature of attending doctor: