Health and Safety
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
*Your Phone No
Address Line 1
(eg building name)
Address Line 2
Address Line 3
*Does the affected person usually work at the above address?
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About where the affected person usually works
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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
Affected person's employment status
*Was the affected person:
one of your employees?
on a training scheme?
employed by someone else?
on work experience?
self-employed and at work?
Details if the affected person was on a training scheme/employed by someone else
*What was the person's occupation or job title?
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About the disease and work that led to the disease
*Date the disease was diagnosed/confirmed
*Was the condition contracted onshore or offshore?
Disease category diagnosed
Disease help (provides help
on the Disease selected)
Specify the diagnosed disease
*and the work activity which gave rise to it
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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