Free OD-2 Form - Nevada

Firemen And Police Officer's 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 FIREMAN) 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 Date

Form OD-2 (rev. 7/99)