NYC 9/11 Public Portal Document
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CITY OF WEW YORK
CNVIRONMENTAL PROTECTION
Cem TAL APA TIO' SNOT AND ON ORCTI AL
ORAM TRALNING 2D CLETHAC ATION UME
EMLFUDDR CORONA NEW YORE UG!
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et SDAP PICTION QQULE YARD.
APPLICATION FOR ASBESTOS INVESTIGATOR
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; ‘APPENDIX A
MEDICAL EXAMINATION FOR ASBESTOS INVESTIGATORS
APPLICANT NAME \
" HOME AODRESS:
CITY, STATE, a ZIP
TELEPHONE yun
DATE OF BIRTH: 7
SOCIAL SECU RITY:
: BASED. UPON THE MEDICAL EXAMINATION: WHICH INCLUDED
. ‘PULMONARY: FUNCTION [TESTS OF NITAC. CAPACITY (FVC)
AND FORCED EXPIRATORY VOLUME AT ONE SECOND
(FEV1): AND AN EVALUATION OFA RECENT, CHEST.
ROENTGENOGRAM, IT IS:MY. OPINION THAT. THE ABOVE
; NAMED ie aad (PLEASE CHECK A) APPROPRIATE BOX)
As | [J IsNnor
PHYS ALLY QUALIFIED TO WEAR A RESRIRATOR IN THE
PERFORMANCE CF HIS/HER JOB.’
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NYC-WTC_000120445
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NYC-WTC_000120445Source: NYC Law Department, mirrored locally