Firemen And Police Officers Lung Examination Form
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Firemen And Police Officers Lung Examination Form. This is a Nevada form and can be use in Workers Comp.
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Tags: Firemen And Police Officers Lung Examination Form, OD-2, Nevada Workers Comp,
Firefighters and Police Officers Lung Examination Form Name (Last, First, Middle) Sex Date of Examination Address Age Date of Birth Personal Physician's Name Occupation PHYSICAL HEIGHT WEIGHT CHEST X-RAY NORMAL ABNORMAL (Specify) BLOOD PRESSURE OVERWEIGHT? YES NO STETHOSCOPIC EXAMINATION OF THE LUNGS NORMAL ABNORMAL (Specify) SPIROMETER TEST* (OPTIONAL FOR VOLUNTEER FIREFIGHTERS) NORMAL *Spirometer testing is to be conducted in accordance with Social Security Regulations entitled "Rules for Determining Disability and Blindness", SSA Publication No.64-014, I.C.N. 436850, June 1985 ABNORMAL (Specify) It is recommended that you contact your personal physician for advice concerning correction of . . . Examiner's Signature Date Please sign one copy of this form and submit it to your employer or organization. Employee's Signature Form OD-2 (rev. 06/14) Posted 6/27/14 American LegalNet, Inc. www.FormsWorkFlow.com Date
