EFTA01710219Set 10
2001-07-0197p30,081w
Injuries: explain)
(attach narrative it additional space needed)
C. LABORATORY
Hemoglobin/Hematocrit Stool 1O & P)
Tuberculin test:
Lead Sickle Cell
Authorized Signature
OH 3040. 10190 (Replaces NRS-li Form 3040 which ... additional space needed)
C. LABORATORY (as Indicated) tYP
mylotin/Hematocril Stool (0 &12)
Lead Tuberculin test:
Sickle Cell resu
NAME:
TITLE:
ADDRESS:
(Please Print)
MRS-li Form 3040, Mar 91 (Obsoletes ... additional space needed)
C. LABORATORY (as indicated)
HemogistinrHernalocrit Stool (0 8 PI
Tuberculin test:
Lead Sickle Cell
al
NAME:
TITLE:
ADDRESS:
(Please Print)
12S -I1 Form 3040, Mar 91 (0bsotetcs
https://www.justice.gov/epstein/files/DataSet%2010/EFTA01710219.pdf