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CG 5197 OCCUPATIONAL HEALTH SURVEILLANCE QUESTIONNAIRE Form
And activity. Use additional sheets as needed. POTENTIAL HAZARDS EXPOSED TO JOB TITLE AND WORK ACTIVITIES Reset PHYSICAL Noise vibration etc CHEMICAL Heavy metals Freon solvents etc PROTECTIVE EQUIPMENT WORN Respirator ear plugs Page 1 of 3 SECONDARY MOONLIGHTING JOBS YOU HAVE HELD Firefighter farmer etc. JOB TITLE HOBBIES AND ACTIVE SPORTS Past and present such as painting woodworking scuba diving etc. DATES WORK RELATED EXPERIENCES COMMENT ON Those you feel may have been harmful to your...Show details
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