SAMPLE LETTER (A reasonable facsimile of this letter, on the medical examiner's letterhead is appropriate. If the medical examiner's name and address do not appear on the letterhead, they must be provided in the letter) Date: I, , hereby acknowledge receipt of the following form(s) provided by the medical examiner: Firefighters and Police Officers' Medical History Form (OD-1) Firefighters and Police Officers' Lung Examination Form (OD-02) Firefighters and Police Officers' Extensive Heart Examination Form (OD-3) Firefighters and Police Officers' Limited Heart Examination Form (OD-4) Hearing Examination Form (OD-5) Firefighter/Police Officer: Name: Address: Signature: Medical Examiner: Name: Address: Signature: (OD-6 rev. 06/14) Posted 6/27/14 American LegalNet, Inc. www.FormsWorkFlow.com