Document 5L1nmzkpmg9kgNLK275GMOdp5

yss 7 R&S 009703 VCM Epidemiological Study - Individual Work History Form A - Workers known to be alive 1, Date of birth o o ^ - (JL2. Date hired o a - x, o - 1 Status: 3. Now employed o\ 3 3________ 4. Retired (give date) _________ 5. Terminated (give date) _____ 6. If retired or terminated, please state how you know that this man is alive. Job history with estimated exposure Xitle Check estimated exposure in ppm ^50 50-199 . .200-500 >500 from to / 2 ' 2~ from to (s ''/? l from > > to i from V j ' to /o - U*\ !--------------------------------------- - - ............ from 10 - O') to 2 - 1" 1. r ;- from "l - 22 to 52from / - - to tr ~9( I X 6 ~ `a V f- rr /