Document G5pepZ05wQYRRLne0kD29YMXN

w - -V Ai ` Q1 Employee's Name Employer <** t i : f' l^( at>C /*) ( . (r / U Medical No. Location , *-"s kV. & C^ctyt't t . j} WAIVER OF MEDICAL EXAMINATIONS /, . , indicate by signing this document, that / refuse to take the medical examinations made available to me by my employer. I understand these examinations are offered as a protection against any toxic substances that I come into contact with in my daily work and I understand the possible medical hazards involved with these substances. Witness Signature of Employee Witness Date WAIVER OF PORTION OF MEDICAL EXAM t. iKc'*~ t v c r' j waive the ______________________________ _____portion of my medical examination. / understand the possible results arid evaluations obtained from my examination may be hindered by the refusal of this por tion of the testing. Ljr. d u r^~ r -- ' *K r u7f j. c7 ^ o c ' L, i . V / / / +?(,, I / /' V Witness Signature of Employee Witness Date /o ^ 7-/ WAIVER OF RESPIRATOR EXAM /,______________________________________________ understand that Federal Regulation 29 CFR 1910.134 requires a medical examination and certification by a licensed physician to wear a respirator. / understand the consequence of this refusal places myself in jeopardy since the Company cannot legally provide me with a protective respiratory device. Witness Witness Signature of Employee Date CCR 000081058 (WHITE COPY TO AHP, NASHVILLE. CANARY COPY TO PLANT MEDICAL RECORDS. PINK COPY TO PLANT MANAGEMENT) Form No.005 (Rav. 1/79)