Member Name Date of Birth Municipal Name Original Date of Active FF As Most Recent Physical Interior - Up to 5 Went Inactive - No Inactive Less Than Of Exam - Detect No Most Recent Fit longer Responding 5 Years: Continue 01/01/2019 Cancer Tests Faithfully to Calls (Reduced) Rate (Yes or No) (MM/DD/YYYY) (MM/DD/YYY) (MM/DD/YYY) Membership (MM/DD/YYYY) (If Applicable) (MM/DD/YYYY) Name of Entity: Year : 2019 If department complies with 1910.134 (OSHA Respiratory Standard), you should have these records available to verify. Verified By:
Name of Entity: Year : 2019 Member Name Date of Birth (MM/DD/YYYY) Municipal Name (If Applicable) Original Date of Membership (MM/DD/YYYY) Active FF As Of 01/01/2019 (Yes or No) Most Recent Physical Exam - Detect No Cancer (MM/DD/YYYY) Interior - Up to 5 Most Recent Fit Tests (MM/DD/YYY) Went Inactive - No longer Responding Faithfully to Calls (MM/DD/YYY) Inactive Less Than 5 Years: Continue (Reduced) Rate If department complies with 1910.134 (OSHA Respiratory Standard), you should have these records available to verify. Verified By:
Eligibility-Roster.docx