The Arunachal Pradesh Occupational Safety, Health and Working Conditions Rules, 2022
Form VIA
Official text
Open in the official PDF (p. 205)
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[See Rule-11(1)]
Notice of Disease
1. Name of establishment :
2. Nature of establishment :
3. Details of Patient :
(a) Name of Patient :
(b) Works number of Patient :
(c) Address of Patient :
(d) Precise occupation of patient :
4. Nature of disease from which patient is suffering :
5. Date of Detection of Disease :
6. Details of Medical Practitioner :
7. Has the case been reported to the Medical Officer :
Date:
Signature of employer or occupier or manager