FAO Fellowship on locust issues (CCA) - Form 6
“Programme to improve national and regional locust management
in Central Asia and Caucasus (CCA)”
FORM 6. Health Certificate
INSTRUCTIONS: To be completed in duplicate by a registered medical practitioner.
Name of candidate
(last)
(first)
Nationality
Date of birth
(middle)
Sex
Marital Status
Address
1. Is the person examined at present in good health, enjoying full working
capacity and is fit for travel and field work?
2. Is the person examined able physically and mentally to carry on intensive
study away from his home?
3. Is the person examined free from infectious diseases (for instance tuberculosis
and trachoma) which could present risks for both the candidate during his
fellowship and his contacts?
Note: A chest X-ray must be taken. It does not need to be sent with this form but
must be available if required. If the fellowship does not start until 6 months after the
date on this certificate, a new medical certificate, confirming that there is no change
in the state of health, will be required. If it starts later than one year after this date, a
complete re-examination will be necessary.
Name of Physician’s:
Physician’s contact details (address, tel, e-mail):
…………………………
Date
…………………………………………..
Physician’s signature