Return the original completed form with an application for contractor/supervisor or worker asbestos license to the
Iowa Division of Labor at the above address. The medical questionnaire from 29 CFR 1926.1101, Appendix D, is for the
use of the physician and is not to be returned to the Iowa Division of Labor. The accuracy of this certification may be
verified by the Iowa Division of Labor. Falsification of a physician’s signature or other attempts to fraudulently obtain
an asbestos license may result in criminal charges, denial of your application, forfeiture of your application fee, denial
of any future applications for asbestos licenses and a civil penalty of up to $5,000.00
STATE OF COUNTY OF
Signed and sworn to (or affirmed) before me on this day of , 20 ,by .
NOTARY PUBLIC in and for the State of
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
150 Des Moines Street
Des Moines, IA 50309-1836
I certify that I have performed a physical examination of the above applicant on the date indicated. I have read the
mandatory OSHA guidelines for this physical in 29 CFR 1910.134 and 1926.1101 and the examination I conducted was in
accordance with the OSHA guidelines. I performed a physical examination of the applicant focused on the pulmonary and
gastrointestinal systems, including tests of forced vital capacity and forced expiratory volume at one second. I interpreted
and classified the applicant’s chest in accordance with 29 CFR 1926.1101, Appendix E. The applicant was informed of the
result of the examination and of any medical conditions which require further explanation or treatment. The applicant was
informed of the increased risk of lung cancer attributed to the combined effects of smoking and asbestos exposure. I have
determined that the applicant is capable of working while wearing a negative pressure respirator without restriction.
I CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE.
Physician’s Signature Date License Number Date of Exam