Firefighters And Police Officers Lung Examination {OD-2}

Firefighters and Police Officers Lung Examination Form Name (Last, First, Middle) Sex Date of Examination Address Age Date of Birth Personal Physician's Name Occupation PHYSICAL HEIGHT WEIGHT CHEST X-RAY NORMAL ABNORMAL (Specify) BLOOD PRESSURE OVERWEIGHT? YES NO STETHOSCOPIC EXAMINATION OF THE LUNGS NORMAL ABNORMAL (Specify) SPIROMETER TEST* (OPTIONAL FOR VOLUNTEER FIREFIGHTERS) NORMAL *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 ABNORMAL (Specify) It is recommended that 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 Form OD-2 (rev. 06/14) Posted 6/27/14 American LegalNet, Inc. www.FormsWorkFlow.com Date