Treating Physician Information Form/authorization For Release Of Medical Records Form - September 11th Victim Compensation Fund - Page 4

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** This form should be completed by the Claimant **
5. Describe the activities that the Claimant was engaged in while responding to this event,
noting the approximate locations that these activities occurred.
6. Please describe the type of exposure hazards that you feel were encountered by the
Claimant during his/her response activities.
7. Please describe the adequacy of the Personal Protective Equipment (PPE) that was
utilized by the Claimant during his/her response activities, noting any breaches of this
PPE that may have occurred.
8. Optional – Please use this space to provide additional comments for consideration.
** End of Responder – Pentagon and Shanksville, PA Form **
Page 2
P.O. Box 34500, Washington, D.C. 20043

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