CITY OF NEW YORK
DEPARTMENT OF ENVIRONMENTAL PR[nECflON
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APFUCA71ON FOR ASBESTOS V4MnCA3OR
AND RESTRICTED ASBESTOS INVESI1GATOR CENT LFJCAflON
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HOME ADDRESS:
CITY, STATE. & ZIP.
TELEPHONE NUME
DATE OF BIRTH:
SOCIAL SECURITY
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 tPLEASE CHECK N) APPROPRIATE BOXI
ld - 0 IS NOT
PHYSICALLY QUALIFIED TO WEAR A RESPIRATOR IN THE
PERFORMANCE OF HIS/HER JOB.
U
) 2 C)
PRINT NAME OF PHYSICIAN DATE OF EXAMINATION
SIGNATURE OF PHYSICIAN ADDRESS
STATE LICENSE NUMBER TELEPHONE NUMBER
DEA; _+ T=: QJ
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NYC-WTC 000120451
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NYC-WTC_000120451Source: NYC Law Department, mirrored locally