श्रम आयुक्त 
(PRESCRIBED UNDER RULE 97)
- TO BE FILLED IN BY THE
- CHIEF INSPECTOR,
- NO. OF CASE REMARKS
- NOTICE OF POISONING OR DISEASE
- (SEE INSTRUCTION ON REVERSE)
| 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 Works 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 |
| Signature of Factory Manager | ||
| Dated | ||
NOTICE OR POISONING 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 notice thereof to such authorities, and in such form and within such time, as may be prescribed.