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' <br /> ' <br /> NIINNESOTA OCCUFATI�NAL HEALTH <br /> ' 1661�t Anthom�p Avrnua St Paul,MN 55104 Telephone(6S1)646-0491 <br /> ' Namo of Employee�rr•.i �,� 1�}r�.n.� <br /> Social Securiry' # t�,_-_�- ��$' <br /> , Company U�� �-F� � T�}V � <br /> PHYSICIAN'S�XAMINATIUN AND FINDINGS <br /> � {To be completed by Physician) <br /> T have examined the individual named above and finc�: (circle one) <br /> � No physical or medical z�easo�n to prohibit this cmployee from participario�in a <br /> � <br /> progra,m which may requixe th�use of respuatvrs. <br /> ' 2. Physical or medical reasvns require the followirig resixictions on participation in a <br /> program which may reqttize the use of respirators. <br /> ' <br /> ' <br /> ' 3. No respirator use is permitted for tb.is i�dividual at this time. <br /> 'Tt�e employce has been infonned b e{the undersigned physici.an)of the results of the medical examination, <br /> ' incroased rislc of lung cancer ' utable to the combined offect of smokixsg and ashestos exposurc. <br /> Yes No N/A <br /> ' Physician Signature <br /> ' Physician Name(Please typo or printj �� •�!=� <br /> Address 1661 5t Anthony Avcnue,St Paul,MN SS 104 <br /> , Phone Numb�r(615)-646-0�91 Date � / y c�/ � �-- ` <br /> ' <br /> , <br /> � <br /> 1 <br />