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75 Virick Street, Suite 501
New York, NY 1001.E-1917
Tel: 212 • 965 • 1730
F~-: 212 • 965 • 1725
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MEDICAL EXAMINATION FOR RESPIRATORY PROTECTION
I
APPLICANTS
HOME ADDRESS
TELEPHONE Nd ii
DATE OF BR
SOCIAL SECU
NOl' VALID WITHOUT
EMBOSSED SEAL
X
BASED UPON THE MEDICAL WHICII INCLUDES:
CAPACITY (FVC). FORCED VITAL
I. PULMONARY FUNCTION TESTS (SPIROMETRY) OF FORCED VITAL
CAPACITY (FVC), FORCED EXPIRATORY VOLUME AT ONE SECOND (FEVI) AND INTERPRETATION.
RADIOLOGICAL SERVICES PROVIDED BY A
2. A CHEST ROENTGENOGRAM, TWO (2) VIEWS AND
QUALIFIED INTERPRETER.
3. MEDICAL HISTORY
AND GASTROINTESTINAL SYSTEMS
4. A PHYSICAL EXAMINATION DIRECTED TO THE PULMONARY
LIMITED TO HEIGHT, WEIGFIT, d OD PRESSURE, PULSE AND RESPIRATION.
INCLUDING BUT NOT
OR IS NOT I'I IYSICAL.LY QUALIFIED TO
IT IS MY OPINION THAT THE ABOVE NAMEI) PATIENT IS
WEAR A RESPIRATOR IN THE PERFORMANCE OF IilS/IlER J013:
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QUALIFIED WITH REFERRAL UNQUALIFIED
DISPOSITION: QUALIFIED
SPIROMETER: CHEST X-RAY:
f COMMENTS:
Pil
NYC-WTC 000120481
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000120481Source: NYC Law Department, mirrored locally
Technical report by Precision Testing & Balancing documenting the testing and balancing of existing supply air systems at the Mayor's Office of Emergency Management dated February…