The disease you are reporting
1 Please give:
• the name of the disease, and the type of
work it is associated with; or
• the name and number of the disease
(from Schedule 3 of the Regulations – see
the accompanying notes).
2 What is the date of the statement of the doctor who first
diagnosed or confirmed the disease?
3 What is the name and address of the doctor?
Describing the work that led to the disease
Please describe any work done by the affected person
which might have led to them getting the disease.
If the disease is thought to have been caused by exposure to
an agent at work (eg a specific chemical) please say what
that agent is.
Give any other information which is relevant.
Give your description here
Continue your description here
Where to send the form
Incident Contact Centre, Caerphilly Business Centre,
Caerphilly Business Park, Caerphilly, CF83 3GG.
or email to email@example.com or fax to 0845 300 9924
For official use
Client number Location number
INV REP Y N