DEPARTMENT OF ENVIRONMENTAL PRO
BUREAU! OF U"MONUEWA1 R.D.(EDUfw AND D: :• .
ASHMUSCO ROLPROGRAM-TRA11WCANDcERflnC
/1JNCn0tJ EOULFVARD. SIB riC,OR. CORONA. ND FIk.1ld!
APPLICATION FOR ASBESTOS INVESTIGATOR
AND RESTRICTED ASBESTOS INVESTIGATOR CERTIFICATION
• LAPPENDIX J A
I ..
MEDICAL EXAMINAYION FOR ; TQSahIV.E
ii
APPLICANT NAME'
HOME ADDRESS: s
CITY. STATE, ZIPS
TELEPHONE NUMB
DATE OF BIRTH:
SOCIAL SECURITY 1 ,~
F;ASED UPON THE MEDIC.Q EXAMINAflON WHICH INCLU
PULMONARY FUNCTION TESTS OF VITAL CAPACITY (I=VC
AND FORCED EXPIRATORY VOLUME AT ONE SECOND
(FEV1). AND AN EVALUATION OF A RECENT CHEST
ROENTGENOGRAM, IT IS MY OPINION THATTHE ABOVE
NAMED PATIENT IPL EASE CHECK ('I) APPROPRIATE BOX)
S
IS NOT
PHYSICALLY QUALIFIED TO WEAR A RESPIRATOR IN THE
PERFORMANCE OF HIS/HER JOB.
PII
NYC-WTC 000120521
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000120521Source: NYC Law Department, mirrored locally