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To be filled in by the
Chief Inspector,
No. of case Remarks |
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NOTICE OF POISONING OR DISEASE |
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(See Instruction on reverse) |
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Factory Particulars |
1. |
Name of Factory |
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Address of factory |
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3. |
Address of office or private residence of occupier |
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4. |
Nature of industry |
Person Affected |
5. |
Nameand Works Number of Patient |
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6. |
Address of Patient |
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7. |
Sex and Age of Patient |
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8. |
Precise occupation of Patient |
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9. |
Nature of Poisoning or Disease from which patient is suffering |
General Particulars |
10. |
Has the case been reported to the Certifying Surgeon |
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Signature of Factory Manager |
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Dated |
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NOTICE OR POISONING DISEASE |
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Extract from the Factories Act, 1948
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(Section 89)
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Where any worker in a factory contracts any disease specified in the Schedule, the manager |
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of the factory shall send notice thereof to such authorities, and in such form and within such |
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time, as may be prescribed. |
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