NYC 9/11 Public Portal Document
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APPLICATION FOR ASOESTOS INVESTIGATOR
MEDICAL EXAMINATION FOR ASBESTOS INVESTIGATORS
APPLICANT NAME 1
~ HOME ADDRESS:
"CITY, STATE, & ZIF
TELEPHONE yun
" DATE OF BIRTH: :
SOCIAL SECURITY
: BASED. UPON ‘THE MEDICAL EXAMINATION: WHICH INCLUDED
. “PULMONARY: FUNCTION [TESTS OF NITAL, CAPACITY (FVC)
AND FORCED EXPIRATORY VOLUME AT ONE SECOND
(FEV 1); AND AN EVALUATION OFA RECENT. CHEST.
ROENTGENOGRAM, IT IS:MY. OPINION THAT. THE ABOVE
NAMED PATIENT (PLEASE CHECK A) APPROPRIATE BOX)
IS [7] Is Not.
t
ANY
PHYSJCALLY QUALIFIED TO WEAR A RESRIRATOR IN THE
PERFORMANCE CF HIS/HER JOB.
NYC-WTC_000120447
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NYC-WTC_000120447Source: NYC Law Department, mirrored locally