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Title:
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Dr
Miss
Mr
Mrs
Ms
Firstname:
Surname:
Job Title:
Telephone:
Email:
Company
Name:
Postcode:
If you don't live in Northern Ireland, or you can't find your address, enter your address below.
Property:
Street:
Locality:
Town:
County:
Email:
Does the affected person usually work at this address?:
Affected person works at address
No
Yes
No - Where do they normally work?:
What type of work does the organisation do?:
Affected Person
Title:
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[choose]
Dr
Miss
Mr
Mrs
Ms
Firstname:
Surname:
Age:
Gender:
Gender of person
Female
Male
Job Title:
[choose]
[choose]
AGRIC/ MANAGERS - agricultural, farms, horticulture, forestry, fishing
AMBULANCE
ARMED FORCES
BAKERY
BREWERY
BRICKLAYER/MASON
BUILDER
BUS COACH DRIVER
BUTCHER
CAR / CAB DRIVER
CAR PARK ATTEND
CARETAKERS
CATERING ASSIST
CHILDCARE
CLEANERS
CONDUCTOR
COOKS CHEFS
CRANE DRIVERS
CUSTOMS / EXCISE
DENTAL
DOCKS
DOOR-TO-DOOR
ELECTRIC FITTER
ELETRIC / GENERAT
ENGINEER / TECHNOL
ENVIRONMENTAL
FIRE WORKER
FISHING
FISHMONGER
FITTER
FLOORER
FORESTRY
GARDENER
GENERAL MANAGERS - national & local government;
GLASS CERAMIC
GOODS DRIVER
HAIR BEAUTY
HOSPITAL PORTER
HOTEL/ RESTAURANT
HOUSEKEEPERS
LABORATORY TEST
LAUNDRY
LAW
LITERARY/MEDIA
MANAGERS/ADMIN - administratior of educational establishments
MEDICAL
METAL FURNACE
MINE / QUARRY
MINING
OFFICERS/CIVIL - police officer inspector or above
OTH AGRICULTURE
OTH CONSTRUCTION
OTH FOOD DRINK
OTH HEALTH
OTH LABOUR
OTH MACH/ PLANT
OTH MISC
OTH PROFESSIONAL
OTH PUBLIC
OTH SALES
OTH TRANS / MACH
PAINTER / DECORATE
PAPER/WOOD
PATIENT - medical/residential
PETRO / CHEMICAL
PLANT DRIVERS
PLASTERER
PLASTICS
PLUMBER / HEATING
POST/ MESSAGE
PRINTING
PRISON
PRISONER
PUBLIC - Member of public
RAIL TRACK
REFUSE
ROOFER
RUBBER
SALES ASSIST
SCAFFOLD/ TEEPLE
SCIENTIF / LAB
SCIENTIFIC
SCRAP METAL
SECURITY
SERVICE/PIPES
SHIP/ AIRCRAFT
SOCIAL SUPPORT
SPORT/ ENTERTAIN
STEEL ERECTOR
SURVEYOR/ PLANNER
SYNTH FIBRE
TANNERY
TEACHING
TECH / WHOLESALE
TEXTILE WORKER
TRANSPORT INSPEC
VEHICLE TRADES
VETS
WAITER/BAR
WATER/ SEWAGE
WELDERS
WINDOW CLEANER
WOOD TRADES
Status:
[choose]
[choose]
EMPLOYED BY SOMEONE ELSE
EMPLOYEE
MEMBER OF PUBLIC
OTHER
SELF EMPLOYED
TRAINEE
WORK EXPERIENCE
If ‘Other’ or ‘Employed by somebody else’,specify details:
Doctor
Title:
[choose]
[choose]
Dr
Miss
Mr
Mrs
Ms
Firstname:
Surname:
Postcode:
If you don't live in Northern Ireland, or you can't find your address, enter your address below.
Property:
Street:
Locality:
Town:
County:
Disease
Disease Type:
[choose]
[choose]
ACNE FROM WORK INVOLVING EXPOSURE TO MINERAL, OIL, TAR, PITCH OR ARSENIC
ANGIOSARCOMA OF THE LIVER
ANTHRAX
ASBESTOSIS
BARATRAUMA RESULTING IN LUNG OR ORGAN DAMAGE
BLADDER CANCER
BLOOD DYSCRASIA DUE TO IONISING RADIATION
BRUCELLOSIS
BURSITIS OR SUBCUTANEOUS CELLULITIS AT OR ABOUT THE ELBOW
BURSITIS OR SUBCUTANEOUS CELLULITIS AT OR ABOUT THE KNEE
BYSSINOSIS
CANCER OF A BRONCHUS OR LUNG
CANCER OF THE NASAL CAVITY OR ASSOCIATED AIR SINUSES
CANCER OF THE URINARY TRACT
CARPAL TUNNEL SYNDROME
CATARACT DUE TO ELECTROMAGNETIC RADIATION
CHLAMYDIOSIS (AVIAN & OVINE)
CHROME ULCERATION (NOSE, THROAT, THE SKIN OF THE HANDS OR FOREARM)
CRAMP OF THE HAND OR FOREARM DUE TO REPETITIVE MOVEMENTS
DECOMPRESSION ILLNESS
DYSBARIC OSTEONECROSIS
EXTRINSIC ALVEOLITIS (INCLUDING FARMERS LUNG)
FOLLICULITIS FROM WORK INVOLVING EXPOSURE TO MINERAL, OIL, TAR, PITCH OR ARSENIC
HAND-ARM VIBRATION SYNDROME
HEPATITIS
INFECTION ATTRIBUTABLE TO SPECIFIED WORK (SCHEDULE 3 NO. 27)
INFLAMMATION, ULCERATION OR MALIGNANT DISEASE OF SKIN DUE TO IONISING RADIATION
LEGIONELLOSIS
LEPTOSPIROSIS
LUNG CANCER
LYME DISEASE
MALIGNANT DISEASES OF THE BONES DUE TO IONISING RADIATION
MESOTHELIOMA
OCCUPATIONAL ASTHMA
OCCUPATIONAL DERMATITIS
PERIPHERAL NEUROPATHY
PNEUMOCONIOSIS (EXCLUDING ASBESTOSIS)
POISONING BY ANY SUBSTANCE IN SCHEDULE 3 NO. 28
PRIMARY CARCINOMA OF THE LUNG WHERE THERE IS ACCOMPANYING EVIDENCE OF SILICOSIS
Q FEVER
RABIES
SKIN CANCER FROM WORK INVOLVING EXPOSURE TO MINERAL, OIL, TAR, PITCH OR ARSENIC
STREPTOCOCCUS SUIS
SUBCUTANEOUS CELLULITIS OF THE HAND
TETANUS
TRAUMATIC INFLAMMATION OF THE TENDONS OF THE HAND OR FOREARM
TUBERCULOSIS
Date Diagnosed:
*
Disease Description:
Date Reported:
*
Fatality:
Disease fatality
No
Yes
District Council:
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[choose]
Antrim and Newtownabbey Borough Council
Ards and North Down Borough Council
Armagh City, Banbridge and Craigavon Borough Council
Belfast City Council
Causeway Coast and Glens District Council
Derry City and Strabane District Council
Fermanagh and Omagh District Council
Lisburn and Castlereagh City Council
Mid and East Antrim Borough Council
Mid Ulster District Council
Newry, Mourne and Down District Council
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