FORM XIV

DOCK WORKERS (SAFETY, HEALTH AND WELFARE) REGULATIONS, 1989
[See Regulation 92 (1)]

To be filled in by the Inspector.........

No. of case..............

Remarks..........

Notice Of Poisoning Or Disease

• Name and address of the employer
• Name of the patient and his work No. if any
• Address of the patient
• Sex and age of the patient
• Precise occupation of the patient
• State exactly what the patient was doing at the time of contracting disease
• Nature of poisoning or disease from which the patient is suffering

  Signature of the Employer

  Date

  Notification of certain diseases

Extract from Regulation 91 of the Dock Workers (Safety, Health an Welfare) Regulations, 1987

1. When a dock worker contracts any disease specified in Schedule IV, a notice Form XIV shall be sent forthwith to the Inspector.

Schedule IV

List of Notifiable Diseases

• Lead poisoning, including poisoning by any preparation or compound of lead or their sequelae.
• Lead tetra-ethyl poisoning.
• Manganese poisoning or its sequelae.
• Carbon bisuiphide poisoning.
• Benzene poisoning, including poisoning by any of its homologues, their nitre or amide derivatives or its sequelae.
• Anthrax.
• Pneumoconosis
• Poisoning by halogens or halogen deriatives of the hydrocarbons of the aliphatic series.
• Primary epitheliomatous cancer of the skin.
• Occupational dermatitis.
• Noise induced bearing loss (exposure to high noise levels).