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HAVE YOU BEEN EXPOSED TO ASBESTOS?
Do you consider yourself to be in good health?
Yes
No
Have you been diagnosed with an asbestos-related disease?
Yes
No
If yes, please select all that apply?
Asbestosis
Pleural Thickening
Pleural Plaques
Lung Cancer
Mesothelioma
Have you ever worked for a year or more in any dusty job?
Yes
No
Have you ever worked with or around asbestos?
Yes
No
What was the timeframe of your last exposure to dust/asbestos?
1940s - 1950s
1960s - 1970s
1980s - 1990s
2000s
Have you or your loved one ever worked as: (Select all that apply)
A carpenter
A construction trade person
An electrician
A plumber and/or pipefitter
A plaster and drywall installer
An auto mechanic or plane mechanic
An insulator
A laborer
A painter
A roofer
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