Document YG6qzrjE8mbG03J6aOz9zN8GK

PRE-PLACEMENT PHYSICAL EXAMINATIONREGoodrich^ The examination must be performed not more than thirty days preceding the employment date. THE FOLLOWING MUST BE COMPLETED BY THE EMPLOYER <Z. APPLICANT'S NAME (LAST. FIRST. MIDDLE INITIAL) SEX - -I1 3$' BIRTH DATE SOC. SEC. NO. HOME ADDRESS (STREET. CITY. STATE, ZONE OR ZIP CODE) PROPOSED JOB ASSIGNMENT DEPT., DISTRICT. OR STORE EXAMINATION REQUESTED BY (NAME OF PERSON) LOCATION AND PHONE NUMBER THE FOLLOWING MUST BE COMPLETED BY THE APPLICANT I hereby certify that all information I provide in connection with this examination is complete and true. I acknowledge that giving false information may be cause for dismissal if hired. I further agree to undergo the medical tests required herein and any others necessary to medically determine my employability. I authorize the examining physician to disclose all information or findings from this examination to The B.F.Goodrich Company to be used for any purpose whatsoever, and I agree to release the examining physician and The B.F.Goodrich Company from all liability for doing so. APPLICANT'S SIGNATURE X DATE ARE YOU NOW? Under the care of a doctor YES NO DESCRIBE FULLY Taking or using any medication, drug, or chemical of any kind. HAVE YOU EVER HAD? An injury on head, face, neck, chest, abdomen, back, shoulder, arm, elbow, hand, leg, knee, or foot Any other major injury An operation on back, face, neck, chest, abdomen, shoulder, arm, elbow, hand, leg, knee, or foot YES NO DESCRIBE HAVE YOU EVER BEEN? Trested for excessive use of alcohol or any other drugs YES NO Rejected for, or released from any military branch of the U.S. forces for medical reasons Compensated for armed forces disability A skin rash or allergy A major or prolonged illness Compensated for occupational illness, disease or injury A nervous or mental illness Epilepsy, convulsive seizures, recurrent fainting attacks Tuberculosis or diabetes Refused an application or charged extra for life insurance MUST BE COMPLETED BY THE EXAMINING PHYSICIAN DESCRIBE The physical examination should be performed with the applicant stripped. A pelvic examination is to be done on female applicants when indicated. A urinalysis is to be done in all cases. Other laboratory and specialized examinations are to be done only when required. In Company facilities use available audiometric and mechanical visual testing equipment, and attach test records. Otherwise, use the hearing and Snellen tests specified and record results in spaces provided. AUDITORY (MARK TEST USED) AUDIOMETER CONVERSATIONAL SPEECH AT 5 FT. RIGHT EAR NORMAL ABNORMAL LEFT EAR NORMAL ABNORMAL VISUAL (MARK TEST USED MECHANICAL TESTING EQUIPMENT SNELLEN CHART CONTACT LENS CHECK IF WORN A. MECHANICAL TESTING EQUIPMENT 1. DISTANT -- without glasses 2. NEAR -- without glasses R. ......................................... R .. ......................................... L L B. 1. distant -- QNFI 1 FN without glasses R............. ............................. L............ CHART L..................................... with glasses R .. L..................................... with glasses R............. L.............................................. w/o glasses R . HEIGHT WEIGHT TEMP. PULSE BLOOD PRESSURE sD Mefr. Liters FEVi Min. VITAL CAPACITY FEVi Tot. Vol. Liters % 1 SEC. % 3 SEC. URINE SP. GP. ALBUMIN SUGAR MICROSCOPIC Special laboratory procedure: A complete blood count, a chest x-ray, or both, will be done only on those applicants designated by The B.F.Goodrich redical Department to receive such examinations, or when, in the opinion of the examining physician, such examinations are necessary in order to operly evaluate the applicant's physical condition. HEMATOLOGY H.C.T. HEMOG (GH) W.B.C. NEUTRO LYMPH MONO. BASO EOSIN CHEST X-RAY FINDINGS BFQ-120S-B RaviMd S/74 BFG65241