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HISTORY AND REPORT OF OMSEP EXAMINATION PART 1 (This form is subject to the Privacy Act Statement of[removed]LAST Name, First Name, Middle Initial: 2. Grade/Rate/Rank: 3. SSN:
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Document Date: 2008-03-27 13:22:09


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Facility

Examining facility / /

IndustryTerm

noise-metals-chemicals / Surveillance protocols / work site / /

MedicalCondition

miscarriages High blood pressure / Infertility / leukemia / stroke Cancer / kidney failure / injury / children Anemia / allergies Epilepsy / hayfever / work-related illness / blood disease / blindness Asthma / emphysema / bronchitis / cystic fibrosis / Birth defects / infectious agents Mental / N Anemia / deafness Other disease / /

MedicalTreatment

Head Surgery / /

Person

Anemia / Surgery Hearing / Set / Surgery Hearing Aid / /

Position

Firearm use Motor Racing Power tool use Head / MEDICAL OFFICER / Chronic ear Infections Ear Drum Rupture Ear/Head / /

Technology

Surveillance protocols / /

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