S-2.1, r. 7 - Regulation respecting pulmonary health examinations for mine workers

Schedule Disposition versions

2012-09-01

SCHEDULE II

(ss. 12 and 13)

PULMONARY HEALTH CERTIFICATE AND NOTICE OF REFERRAL

PART I

PULMONORY HEALTH CERTIFICATE

		
		Commision de la
		santé et de la sécurité
		du travail du Québec		
				Pulmonary health certificate
Name and address of holder			I certify that I have examined the holder of this certificate pursuant to the Regulation respecting
			pulmonary health examinations for mine workers and that, to the best of my knowledge, the
			holder of this certificate is entitled thereto.
2302 (94-12)

PART II

NOTICE OF REFERRAL

		
		Commision de la
		santé et de la sécurité
		du travail du Québec		
					Notice of referral
Name and address of holder			I certify that I have examined the holder of this certificate pursuant to the Regulation respecting
			pulmonary health examinations for mine workers and that, to the best of my knowledge, the 
			holder of this certificate should file a claim for a pulmonary occupational disease relating from
			exposure to:			
						asbestos	
						silica	
			If you fail to file a claim within 6 months following this notice, your pulmonary health 
			certificate will be suspended until such time as you file a claim with the CSST.
2301 (95-04)

O.C. 1325-95, Sch. II.