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Health and Safety

Executive

Health and Safety at Work etc Act 1974

The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013

Report of an occupational disease

About you and your organisation

(eg building name)

(eg street)

(eg district)

*Does the affected person usually work at the above address?

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Health and Safety

Executive

Report of an occupational disease

About where the affected person usually works

(eg building name)

(eg street)

(eg district)

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Health and Safety

Executive

Report of an occupational disease

Affected person details

About the local authority and work activity where the affected person usually works

In which local authority are the premises where the affected person usually works?

Please refer to the help for guidance on the local authority

What type of work was being carried out (generally the main business activity of the site where the affected person usually works)?

About the affected person

*Gender

Affected person's employment status

*Was the affected person:

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Health and Safety

Executive

Report of an occupational disease

About the disease and work that led to the disease

*Was the condition contracted onshore or offshore?

Please check your email address below. Ensure that you change if incorrect as this is the email address that your acknowledgement and a copy of the form will be sent to.

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