Maine Occupational Disease Surveillance Form - Maine Center For Disease Control And Prevention

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MAINE OCCUPATIONAL DISEASE SURVEILLANCE FORM
Please complete this form on all patients with a reportable occupational disease.
CLINICIAN OR FACILITY
Return form to:
Occupational Disease Registry
Name:_______________________________________
Maine Center for Disease Control and Prevention
Environmental and Occupational Health Programs
Address:_____________________________________
rd
11 SHS, 286 Water Street, Key Bank Plaza, 3
Floor.
_____________________________________________
Augusta, Maine 04333-0011
Phone#______________________________________
For any questions: (207) 287-5378 Fax (207) 287-3981 TTY: Relay 711
:__________________________
Contract Person
PATIENT NAME (Last)
(First)
(Middle)
(Maiden or aliases)
PATIENT’S ADDRESS AT DIAGNOSIS
(Street, City, State, Zip Code)
RACE (Check one)
Ethnicity
Date of Birth
Sex (Check one)
Caucasian/White
Black
American Indian
(Month, Day, Yr)
Male
Hispanic
Asian
Unknown
Other______________________
Female
Non-Hispanic
Other__________________
Does Patient Currently smoke?
No
Yes
If yes, how many pack(s) a day?_______________________________
Patient’s Telephone number
Is there any reason we should not contact this patient directly?
Ok to contact patient
(including area code)
Please do not contact the patient for the following reasons(s):_____________________________________
O
/J
T
I
CCUPATION
OB
YPE
NDUSTRY
For fishers, please indicate the method of fishing employed, e.g. diving, trawling,
For fishers, please indicate the type of fish caught or harvested, e.g., scallops,
digging, gillnetting, dredging, etc
lobster, haddock, etc
N
E
And A
AME OF
MPLOYER
DDRESS
T
E
(including area code)
ELEPHONE NUMBER OF
MPLOYER
Date of visit_______________________________________
REPORTABLE DISEASE
I
T
D
__________________________________
F
EST TAKEN COLLECTION
ATE
Please check one of the following:
Work-Related
Not Work-Related
Suspect Work-Related
Unknown
Check all that apply
Agriculturally – related injury (includes farming, logging, and fishing). Please describe how injury occurred, and the physical findings of
the injury._____________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Asbestosis
Byssinosis
Carpal Tunnel Syndrome
Heavy Metal Poisoning
Arsenic (level)_____
Cadmium (level)_____
Lead (level)______
Mercury (level)______
Hypersensitivity Pneumonitis (caused by__________________________________________________________________________)
Mesothelioma
Occupational Asthma (caused by__________________________________________________________________________________)
Outbreaks (agent________________________________________________________________________________________________)
Pesticide Poisoning (name of pesticide_____________________________________________________________________________)
Silicosis
Solvent Toxicity (name of solvent__________________________________________________________________________________)
Toxic Gas Poisoning (
Ammonia
Chlorine
Hydrogen Sulfide )
Other (please describe)__________________________________________________________________________________________________________
Comments:
C
D
:
OMPLETED BY
ATE
October 2012
C
ONFIDENTIAL INFORMATION
H/ables/Maine Occupational disease surveillance form

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