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D P DEPARTMENT OF ENVmONMThJTAL PROTECTION
DUREAU OF L'AU ' NE-r- TAL WD,=AnCN AND
AS&SRXS CQ%TR01YRCOLAM .7RAri'NC AND CERMCA71ONUNf
u,
60-17 JUNCTION DOU[EYAM. (IM ROOK C CRONA, hTw YORK 1
API?I.ICATION FOR ASBESTOS INVESTIGATOR
AND RESTRICTED ASBESTOS INVESTIGATOR CERTIFICATION
APPENDIX A
•
MEDICAL EXAMINATION FOR ASBESTOS INVESTIGATORS
APPLICANT
HOME ADDRESS:
• CITY, STATE, & ZIF
TELEPHONE NUMI
DATE OF BIRTH:
SOCIAL
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 PATIENT (PLEASE CHECK ('I) APPROPRIATE BOX)
IS 0 IS NOT
PHYSICAL Y QUALIFIED TO WEAR A RESPIRATOR IN THE
PERFORMANCE OF HIS/HER JOB.
Pil
NYC-WTC 000120504
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NYC-WTC_000120504Source: NYC Law Department, mirrored locally