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Fill and Sign the Justia Firemen and Police Officers Lung Examination Form

Fill and Sign the Justia Firemen and Police Officers Lung Examination Form

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Open the document and fill out all its fields.
Apply your legally-binding eSignature.
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Fire fighters and Police Officer s Lung Examination Form Name (Last, First, Middle) Sex Date of Examination Address Age Date of Birth Personal Phy sician’s Name Occupation PHYSICAL HEIGHT BLOOD PRESSURE WEIGHT OVERWEIGHT? YES NO CHEST X -RAY NORMAL ABNORMAL (Specify) STETHOSCOPIC EXAMINATION OF THE LUNGS NORMAL ABNORMAL (Specify) SPIROMETER TEST* (OPTIONAL FOR VOLUNTEER FIREFIGHTERS ) NORMAL ABNORMAL (Specify) *Spirome ter 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 It is recommended tha t 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 Date Form OD -2 (rev. 06/14)

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