Physician'S Report Form On Occupational Disease
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Physician's Report of Occupational Disease
Connecticut Departments of Labor and Public Health
This information is reportable by law within forty-eight (48) hours under CGS Sec.31-40a
Date of Report:______/______/______
and confidential under CGS I-19(b)(2) and 19a-25
please type or write clearly
I. Patient (Employee) Information
Name:_______________________________________________________________________________________________________SSN:________/________/________
Last
First
MI
Address: __________________________________________________________________________________________________________________________________
Street
City
State
Zip Code
o Male
o Female
Home Phone #: (
) ________-________
Date of Birth: _____/_____/_____
Gender:
o Yes
o No
o Unknown
o American Indian
o Asian
o Black
o White
o Other
o Unknown
Hispanic:
Race:
Occupation (at time of exposure)__________________________________________________(present)______________________________________________________
II. Occupational Illness/Injury Information (ICD-9)
Repetitive Trauma Disorders
Respiratory Diseases/Disorders
Poisonings and toxic effects
o Carpal Tunnel Syndrome (354.0)
o Allergic Rhinitis (477)
o Carbon Monoxide (986)
o DeQuervains Syndrome (727.04)
o Asbestosis (501)
o Lead (984) _______µg/dL (Attach copy of lab report)
o Epicondylitis (Tennis Elbow) (726.32)
o Asthma (493)
o Solvents (982)
o Hand-Arm Vibration Syndrome (443.0)
o Bronchitis (491)
o Cancer (type)_________________________(
)
o Raynaud’s Syndrome (443.0)
o Pleural Plaques (511.0)
o OTHER (specify)______________________(
)
o Thoracic Outlet Syndrome (353.0)
o Reactive Airway Dysfunction Syndrome (506)
o Trigger Finger (727.03)
o Rhinitis (472.0)
Noise Disorders
o Vibration White Finger (443.0)
o Silicosis (502)
o Hearing Loss (389)
o Bursitis (site) _______________________ (727.3)
o Sinusitis (473)
o Tinnitis (388.3)
o Ganglion/ Cystic Tumor (site)__________ (727.4)
o OTHER (specify)___________________(
o OTHER (specify)______________________(
)
)
o Synovitis (site)______________________ (727.0)
o Tendonitis (site)____________________ (726.90)
Infectious Processes
Skin Diseases/Disorders
o Tenosynovitis (site)__________________ (727.0)
o Hepatitis B (070.3)
o Contact Dermatitis (692)
o OTHER (specify)___________________ (
o Tuberculin conversion (010)
o OTHER (specify)______________________(
)
)
o OTHER (specify)___________________(
)
o Injury (specify type and site on diagnosis line below)
Diagnosis (if not listed above):___________________________________________________________________________________ICD-9(s) ___________________
Symptoms/Physical Findings:__________________________________________________________________________________Date of First Symptom:____/____/____
Suspected causal factor(s) (i.e., object, substance or event):__________________________________________________________________________________________
Exposure: o Acute o Chronic
Is patient exposure continuing? o Yes o No o Unknown
Are others likely to be affected? o Yes o No o Unknown
Certainty of work relatedness: o High
o Moderate
o Low
Length of employment in occupation of concern: ________yrs_______months
Comments:________________________________________________________________________________________________________________________________
III. Employer Information (where exposure occurred)
Company Name:____________________________________________________________________________________________________________________________
Mailing Address:____________________________________________________________________________________________________________________________
Street
City
State
Zip Code
Phone #: (
) ________-_________
Work site location (if different than above)____________________________________________________________________
IV. Health Care Provider Information
Name:____________________________________________________________________________________________________________________________________
Last
First
MI
(MD, RN, PA, Other)
Institution/Clinic name:______________________________________________________________________________________________________________________
Mailing Address:___________________________________________________________________________________________________________________________
Street
City
State
Zip Code
Phone #: (
) ________-_________
Signature:___________________________________________________________________
For more information call: (860) 566-4550 Labor Department or (860) 509-7740 Department of Public Health
Return to: State of Connecticut Labor Department, Division of Occupational Safety & Health, 38 Wolcott Hill Rd., Wethersfield, CT 06109
ID No.
OC exp
OC present
Nature
POB
SIC
For office use only
Rev. 10/95
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