Form 12

{See Rule 17}

NOTICE OF DISEASE

(1) Name and address of establishment:

(2) Nature of establishment:

(3) Details of Patient:

(a) Name of Patient:

(b) Age and gender:

(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 :

Signature of employer or

occupier or manager

Date: