Patient: HARTMAN WALKER DOB: 01/28/1975

Physician: MERCEDES CAMACHO, FNO DOS: 08/15/2023

OCCUPATIONAL AND COMMUNITY HEALTH SERVICES
3300 Hudson Avenue, Union City, NJ 07087
Tel: (201)325-8002 fax:(201)325-9718 E-mail: ochsclinic@yahoo.com

MEDICAL EVALUATION: ASBESTOS WORK

Last name First Name Social Security Date of Birth
WALKER JR HARTMAN Number 01/28/1975
ANTHONY 123620769
Address Apartment Number Male/Female
75 lark drive 2 MALE
City State/Province Postal Code Home Phone
SOUTH RIVER NJ 08882 551 358 9654
Emergency contact person Emergency Contact Telephone
732 207 2061
The patient indicated above has been evaluated 08/15/2023 in compliance with
on
OSHA Asbestos Medical Screening and Surveillance standard 1910.1001 (29CFR.)
MEDICAL HISTORY REPORT
OSHA standard 1910.134 App C Questionnaire for respiratory protection x unremarkable significant finding
OSHA standard 1926.1101 App D Questionnaire for respiratory protection x unremarkable significant finding

Patient is: X non-smoker smoker __cigarettes/day X___years quit smoking on_________after___________years

Last Chest X-ray dated results: normal abnormal
Respiratory system evaluation within normal limits deviations from normal _________________________________
Gastrointestinal system evaluation within normal limits deviations from normal ________________________________
Cardiovascular system evaluation within normal limits deviations from normal ________________________________

Blood pressure 120/60 HR 80 RR 17 HT 6'2” WT 219 lb. Visual acuity: Lt. Eye Rt Eye._________
Pulmonary function test X Donnal abnormal results attached
Electrocardiogram (per clinician discretion) normal significant deviations from normal N/A
Physical examination X within acceptable limits significant deviations from normal
Chest X-ray: not indicated ordered normal abnormal results pending

RESULTS:
X ABLE TO WORK IN ASBESTOS AND WEAR RESPIRATORY PROTECTION WITHOUT RESTRICTION
ABLE TO WORK IN ASBESTOS AND WEAR RESPIRATORY PROTECTION WITH RESTRICTIONS
CLEARANCE DENIED POSTPONED NEEDS FURTHER EVALUATION OR FOLLOW-UP

SPECIFIC RECOMMENDATIONS:

1. Do not smoke cigarettes. 2. Always wear respirator mask while at work

PATIENT EDUCATION
The patient has been informed of the risks involved in asbestos work and of the Increased risk of lung cancer
attributable [0 the combined effects of smoking and asbestos exposure, and of the increased risk with higher intensity
and duration of exposure. The results of this medical evaluation for use of respirators and asbestos work have been
explained to me (patient). 'Los resultados de esta evaluacion medica han sido explicados a mi persona

THIS MEDICAL EVALUATION REPORT EXPIRES ON: 08/15/2024

This report must be accompanied by numeric and graphical printout of the spirometry results.
Original report and all copies must bear the OCHS watermark seal.

08/15/2023 08/15/2023
Signature of liensed health care provide date date

Patient: HARTMAN WALKER JR DOB: 01/28/1975

Physician: MERCEDES CAMACHO, FNP DOS: 08/15/2023

OCCUPATIONAL & COMMUNITY HEALTH SERVICES

OCHS 3300 Hudson Avenue, Union City, NJ 07087
Tel: (201) 325-8002 Fax: (201) 325-9718 E-mail: ochsclinic@yahoo.com

QUALITATIVE RESPIRATOR FIT TEST REPORT

FIT TEST RECORD NUMBER FIT TEST DATE EXPIRATION DATE

08/15/2023 08/15/2024
FIRST NAME LAST NAME SOCIAL SECURITY NUMBER
HARTMAN ANTHONY WALKER JR 123620769

RESPIRATION DATA

TYPE: APR HALF FACE MODEL:7700-30

MANUFACTURER: NORTH

SIZE: LARGE

TESTING AGENT: IRRITANT SMOKE

POSITIVE PRESSURE TEST: PASS NEGATIVE PRESSURE TEST: PASS

NORMAL BREATHING: PASS

TURN HEAD SIDE TO SIDE: PASS

DEEP BREATHING: PASS NOD HEAD UP AND DOWN: PASS JOG IN PLACE:
PASS

TALK ALOUD: PASS

FACIAL HAIR: NONE

SIGNATURE OF TESTER SIGNATURE OF RESPIRATOR USER

DATE:04/09/2018 ORIGINAL MUST RESPIRATOR BEAR ISES WATER MARK SEAL

LEGAL NOTICE I NOTA LEGAL: This fit-test is personal. The alteration of this document for fraudulent purposes is a
federal crime. La alteracion de este doel/mento para usos fraudulentos es un crimen federal.
OCCUPATIONAL AND COMMUNITY EasyOne(TM) FRONTLINE US 6.7
3300 HUDSON AUE [C]ndd 2000-2011
UNION CITY NJ07087 EasyWare 2.25.0.0-03/27/2017 13:47
2013258002
SN 116398 RecNo 571

Patient Information Test Information

Name HARTMAN WALKER JR
ID 123620769
Test Date/Time 08/15/2023
Age 48 Post Time -:-
Height 6 ft 2 in Test Mode FRONTLINE
Weight 182 lbs. BMI 27.0 Syst, Interpret. NLHEP
Gender MALE Predicted Ref Nhanes Ill
Ethnic AFRICAN AMERICAN Value Select BEST VALUE
Smoker NO Tech ID
Asthma NO Automated OC ON
BTPS (IN/EX] 1.02

FVC Test Results Your FEV1 is 116% Predicted

Parameter best pred %pred

FVC[LI] 6.0 5.1 117
FEV1[L] 4.8 4.1 116
FEV1/FVC[%] 80.3 81.4 99
PE[IL/min] 561.9 605.8 93

Pre-Test FEV1 Var 0.15L 3.1% FVC Var-0.14L 2.3% Session Quality B
Syst. Interpret. Normal Spirometry