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VCM Epidemiological Study - Individual Work History
Form A - Workers known to be alive
1. Date of birth :% o9 ! & 2. Date hired 3
Status : 3. Now employed
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4. Retired (give date)
5. Terminated (give date)
i 6. If retired or terminated, please state how you know that this man
is alive.
R&S 009629
0Job no. #
Job history with estimated exposure
Title _________________________
trM
Check estimated exposure in ppm <50 50-199 200-500 >500
to 3~(jO j
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