NYC 9/11 Public Portal Document
DEP
CITY OF NEW YORK
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TURLAU O DIMRONMDHTAL RDADDLATION AND DNFORODADHI
ASVOSTOS CONTROL FROCIUM. TLUNING AND COKTINCANONLNI
9T1) RINCTIOTI SOLLIVAED ITH PLOOR CORONU NEW TONX IL
APPLICATION FOR ASBESTOS INVESTIGATOR
AND RESTRICTED ASBESTOS INVESTIGATOR CEKTIFICATION
APPENDIX A
MEDICAL EXAMINATION FOR ASDESTOS INYESTIGATORS
APPLICANT NAME:
HOME ADDRESS:
CITY, STATE, & ZIP:
TELEPHONE NUMBE
DATE OF BIRTH:
SOCUL SECURITY N
PII
•
:
:
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 IPLEASE CHECK NLAPPROPRIATE BOXI
D15
IS NOT
PHYSICALLY QUALIFIED TO WEAR A RESPIRATORIN THE
PERFORMANCE OF HISHERJOB.
PII
SIGNATURE OF PHYSICIAN
STATE LICENSE NUMBER
PII
ADDRESS
TELEPHONE NUMBER
NYC-WTC_000120449
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000120449Source: NYC Law Department, mirrored locally