FORM  NO. 19
[Prescribed under Rule 97]
[to be filled in by the Chief Inspector]

Number of case:


Notice of poisoning or disease
(See introduction below)

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.


Signature of factory manager.

Notice of 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.

Extract from the A. P. Factories Rules, 1950 (Rule 97)

A notice in Form No. 19 should be sent forthwith both to the Chief Inspector and to the Certifying Surgeon, by the manager of a factory in which there occurs a case of lead, phosphorus, mercury, manganese, arsenic, carbon bisulphide or by benzene poisoning; or poisoning by nitrous fumes, or by halogens or halogen derivates of the hydrocarbons of the aliphatic series; or of chrome ulceration; anthrax silicosis, toxic anaemia, toxic jaundice, primary, opitheliomataous cancer of the skin, or pathological manifestations due to radium or other radio-active substances or X-rays.