FORM No. 19
Notice of poisoning or disease
(See instruction reverse)
ESIS Employees Code No. Registration No.
ESIS Insurance No Licence No.
Name & Address of the NIG Code No injured persons ( As given in the licence)
Local ESIG Officer
1. Name & address of factory :
2. Name, address & Tel. number :
3. Nature of injury :
4. Particulars of affected workers
(a) Name :
(b) Age :
(c) Sex :
(d) Serial number as per Registration of
:
Adult/Child worker
(e) Address :
(f) Precise occupation :
(g) Nature of job :
5. Nature of
poisoning/disease :
(Give serial number & name as per
the list overleaf)
6. (a) Harmful agent or process to which
:
poisoning or disease is attributed
(b) Approximate date of beginning &
cessation of exposure of the worker to
the harmful agent or process
7. Has the case been reported to the
: Yes/No
certifying Surgeon/Administrative
Medical Officer, ESIS/Medical
Inspector of Factories.
Date : Signature of Manager
Name (In capital letters)
Tel. No.
Note:- This notice should be sent forthwith to the following authorities
(i) Chief Inspector of Factories & Boilers
(ii) Medical Inspector of Factories
(iii) Certifying Surgeon
(iv) Administrative Medical Officer, ESIS
(To be filled in by the Factory Inspector)
Number of the case
Remarks Signature
Date
: Name
( block letters)
Designation
Notice of poisoning or Disease
Extract from the Factories Act 1948 (Section 89)
Where any worker in a factory contracts any disease specified in the schedule, the manager of the factory shall send a notice thereof such authorities and in such form and within such time, as may be prescribed.
Schedule
List of Notificable Diseases
1. Lead poisoning, including poisoning by any, preparation of lead or their sequelae.
2. Lead tetra-ethyl poisoning
3. Phosphorous poisoning or its sequelae
4. Mercury poisoning or its sequelae
5. Manganese poisoning or its sequelae
6. Arsening poisoning or its sequelae
7. Poisoning by nitrouse fumes
8. Carbon disulphide poisoning
9. Benzene poisoning, including poisoning by any of its homologues, their nitro or amide derivatives or its sequelae
10. Chromelceration or its sequelae
11. Anthrax
12. Silicosis
13. Poisoning by halogens or halogen derivatives of the hydrocarbons of the aliphatic series
14. Pathological manifestation due to-
(a) radium or other radio-active substances; and
(b) X-ray
15. Primary epithelionatous cancer of skin
16. Toxic anemia
17. Toxic
18. Oil acne or dermatitis due to mineral oils and compounds containing mineral oil base
19. Byssinosis
20. Asbestosis
21. Occupational or contact dermatitis caused by direct contact with chemicals and paints. These are of two types that is, primary irritants and allerigic sensitizers.
22. Nosie induced hearing loss (exposure to high noise levels)
23. beriyllium poisoning.
24. Carbon monoxide.
25. Coal miners pneumoconiosis
26. Poisoning.
27. Occupational cancer
28. Isoeyanates poisoning
29. Toxic nephrits.