oRIVAGY ACT MATERIAL REMOVED
*
MEDICAL EVALUATION
,
%
This is to certify that I have determined that Eberline
Instrument Corporation employee,
|
a
>
has no unusual medical conditions or physical impairments
that would limit his normal duties of employment.
Base Line Blood Counts:
White Cell with Differential
// Normal
// Abnormal
Hemoglobin /7 Normal /7- Abnormal
Date
s
Physician's Signature
Please type:
Signature Name
Street and No.
City
State
Zip
Telephone
MATERIAL
PRIVACY act
REMOVED