Department of Labour and Employment FORM - 18 (Prescribed under rule 107) (To be filled in by the Chief Inspector) Number of Case: Remarks: Notice of Poisoning or disease Factory particulars __ 1. Name of Factory __ 2. Address of factory __ 3. Address of office or private residence __ of occupier 4. Nature of Industry __ Person affected: 5. Name and work number of patient __ 6. Address of patient __ 7. Sex and age of patient __ 8. Precise occupation of patient __ 9. Nature of poisoning or disease from, __ which patient is suffering General particulars __ 10. Has the case been reported to the Certifying surgeon? Date: Signature of Factory Manager
