Nevada > Workers Comp
Firemen And Police Officers Lung Examination Form OD-2 - Nevada
| Firemen And Police Officers Lung Examination Form Form. This is a Nevada form and can be used in Workers Comp . |
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Firemen And Police Officers Lung Examination Form Name (Last, First, Middle) Sex Date of Examination Address Age Date of Birth Personal Physicians Name Occupation PHYSICAL HEIGHT BLOOD PRESSURE YES NO WEIGHT OVERWEIGHT? CHEST X-RAY NORMAL ABNORMAL (Specify) STETHOSCOPIC EXAMINATION OF THE LUNGS NORMAL ABNORMAL (Specify) SPIROMETER TEST* (OPTIONAL FOR VOLUNTEER FIREMAN) NORMAL ABNORMAL (Specify) *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 It is recommended that you contact your personal physician for advice concerning correction of . . . Examiners Signature Date Please sign one copy of this form and submit it to your employer or organization. Employees Signature Date Form OD-2 (rev. 7/99)
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