Part A
About you
1 What is your full name?
2 What is your job title?
3 What is your telephone number?
About your organisation
4 What is the name of your organisation?
5 What is its address and postcode?
6 Does the affected person usually work at this address?
Yes Go to question 7
No Where do they normally work?
7 What type of work does the organisation do?
Part B
About the affected person
1 What is their full name?
2What is their date of birth?
3 What is their job title?
4 Are they
5 Is the affected person (tick one box)
one of your employees?
on a training scheme? Give details:
on work experience?
employed by someone else? Give details:
other? Give details:
Filling in this form
This form must be filled in by an employer or other responsible person.
Health and Safety at Work etc Act 1974
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
Report of a case of disease
F2508A (05.00)
Click here for report guidance
Part C
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?
Part D
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
Part E
Your signature
Where to send the form
Incident Contact Centre, Caerphilly Business Centre,
Caerphilly Business Park, Caerphilly, CF83 3GG.
or email to or fax to 0845 300 9924
For official use
Client number Location number
Event number
If returning by post/fax, please ensure this
form is signed, alternatively, if returning
by E-Mail, please type your name in the
signature box
Please continue on this page if necessary