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R&S 009307
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VCM Epidemiological Study - Individual Work History
Form C - Workers whose vital status is unknown
1. Date of birth 5;
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3. Date of retirement
2. Date hired
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4. Date of termination
5, If we may trace this man through a retail credit bureau, which will not directly contact him or his family, please give his name and last known address:
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Job history with estimated exposure Title
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from to from to from to
Check estimated exposure in ppm
^50 50-199
200-500 ->500
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R&S 009308