Physician's Written Statement - Medical Surveillance for Asbestos 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the applicant's name, date of birth, and social security number in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the street address, city, state, and telephone number of the applicant. This information helps maintain clear communication.
4. In the section where you note your examination date, specify when you saw the individual. This is essential for tracking medical evaluations.
5. Complete the checklist regarding the standardized medical questionnaire and review of work history. Highlight any relevant findings related to pulmonary, cardiovascular, and gastrointestinal systems.
6. Document any physical examinations performed and results from pulmonary function tests (FVC and FEV1). Include details about chest x-ray results as per regulatory requirements.
7. Conclude with your signature, printed name, address, and contact information to validate the statement. Ensure all sections are filled out completely before submission.

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