Document 21LEXz1MjExm36VNaGd4pmX7

romoiai UNIROYAL. Inc. OXFORD (Lacattont March 27, 1978 TO: R. T. Shearer - Painesvi1le v R. E. Williams - Scotts Bluff R. F. Shortt Naugatuck Chemical RE: WAIVER FORM FOR THOSE EMPLOYEES WHO DECLINE TO PARTICIPATE IN THE ACRYLONITRILE MEDICAL EXAMINATIONS You will recall that in my detailed communication of February 9, 1978 we made comment regarding the handling of possible employee non-participation in the acrylonitrile medical surveillance program. Our recommendation was essentially: "If an employee refuses any required medical examination, the employer shall inform the employee of the possible health consequences of such refusal and obtain a signed statement from the employee indicating that the employee understands the risk involved by refusal to be examined." In the interim since this statement was written and distributed, we hav received a waiver (copy attached) from Patrick R. Laden of Arthur, Dry & Kalish, to be signed by any employee who declines an acrylonitrile medical examination. Mr. Laden has instructed us as follows: "If an employee declines a medical examination and refuses to sign the form, the Saf ty Manager should sign the form and make a notation concerning the empl yee's refusal to sign after declining the Company's offer." U R L-P 3362 JDF/df Attachment cc: E. H. Finkenstadt R. G. Havener B. R. Leach CONFIDENTIAL DOCUMENT PRODUCED PURSUANT TO PROTECTIVE ORDER f MEDICAL EXAMINATION WAIVER My employer, Uniroyml, Inc., has offered me an opportunity to have a free medical examination In accordance with the OSHA standard for occupational exposure to acrylonitrile (AN). I hereby decline this offer and I understand that OSHA has declared acrylonitrile a cancer hatard. Date Signature ) URL-P 3363 CONFIDENTIAL DOCUMENT PRODUCED PURSUANT TO PROTECTIVE ORDER