Document rxeoqE51Yz63LOVwpVvGEjEXa

JOB I 103 S' ASBESTOS EXPOSURE - MEDICAL EXAMINATIONS I, the undersigned Employee for Anco Insulations, Inc!, acknowledge that Anco has told me that I may be or may have been exposed to asbestos in my work and has offered to have me examined by a doctor, at the company's expense, relative to exposure to asbestos. I have checked b.elow whether or not I desire such a medical examination. 1=3 X do desire a medical examination. * I do not desire a medical examination. ^ 6&ZQ8I01S , DATE* /A Note to Employeet OSHA Safety and Health Standards, Section 1910.1001 (j)(1), reads: Medical examinations -(l)General. The employer shall provide or make available at his cost, medical examina tions relative to exposure to asbestos required by this paragraph. DOW 06432