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A S ESM AND LEAD CONTROL 1'ROCRAM. TRAWwc
AND CER Tuic,
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SLIf JUNCTION BOULEVARD.FMFLOOXCORONA.NEW YORK 1134
APPLICATION FOR ASBESTOS INVESTIGATOR
.
AND RESTRICTED ASBESTOS INVESTIGATOR
CERTIFICATION.
4.PPENDIX A:__/
1IEDICAL EXAMINATION FOR ASBESTOS INVESTIGATORS
APPLICANTNAME•
HOME ADDRESS:
CITY, STATE, 8 ZIP:,
TELEPHONE NUMB;
DATE OF BIRTH:
SOCIAL SECURITY I
BASED UPON THE MEDICAL EXAMINATION WHICH INCLUDED
PULMONARY FUNCTION TESTS OF VITAL CAPACITY (FVC)
AND FORCED EXPIRATORY VOLUME AT ONE SECOND
(FEV1). AND AN EVALUATION OF A RECENT CHEST
ROENTGENOGRAM, IT IS MY OPINION THAT THE ABOVE
NAMED PATI NT IPLEASECHECKNI APPROPRIATE BOX)
IS IS NOT
PHYSICALLY QUALIFIED TO WEAR A RESPIRATOR IN THE
PERFORMANCE OF HIS/HER JOB.
Pil •
NYC-WTC 000120491
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NYC-WTC_000120491Source: NYC Law Department, mirrored locally