Hong Kong Regulations

FACTORIES AND INDUSTRIAL UNDERTAKINGS (NOTIFICATION OF OCCUPATIONAL DISEASES) REGULATIONS - SCHEDULE 2

Notice of Occupational Disease

To: Director of Health Notice is hereby given of the following occupational disease- .......................................................................................... confirmed/suspected* .......................................................................................... Possible cause- .................................................................. Date contracted/of recurrence*- ......................................... Name of patient/deceased*- ............................................... Sex- ..................................... Age- .................................. Home address- .................................................................. .................................................................. Employed as- .....................................................................	FOR OFFICIAL USE ONLY Case No.:- Ref. No.:- Action taken:-
Name, address and trade or industry of employer- .................................................................. ............................................................................................................................................ Hospital sent to (if any)- ....................................................................................................... Name and address of notifying medical practitioner- ............................................................... Date- ................................................................................................................. 19 ............ ......................................................................... Signature of notifying medical practitioner * Delete whichever is in applicable.