Contact
Title:
[choose]
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?:
No - Where do they normally work?:
What type of work does the organisation do?:
Affected Person
Title:
[choose]
Firstname:
Surname:
Age:
Gender:
Job Title:
[choose]
Status:
[choose]
If ‘Other’ or ‘Employed by somebody else’,specify details:
Doctor
Title:
[choose]
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]
Date Diagnosed:
Disease Description:
Date Reported:
Fatality:
District Council:
[choose]