Document nN1yBGQjneZwpGrqyGjO8MOE6

F orm 9436 \ U. S .-TREASURY D E P A R T M E N T ,, P u b l ic H e a l t h Se r v ic e . . . (April 1138) THE UNITED STATES PUBLIC HEALTH SERVICE COOPERATING WITH . , .> O H IO DEPARTM ENT O F HEALTH % . sJ S Ut sI b Si ;j g Os Ou cSS s* 5 S I 28 ^ < 'fCa a5s 1UJ I*;Ims 43. S oQ ^ g 3 -- js . B K! il I lt M g Z 03 M ,. CERTIFICATE^ ^ o r o o g j f a io n a l d isea se, Nsriie *>f Patient....__.... ' : ! : '***, (L astnanic)... ....^ ...... iSBIBSB / / {Firstname) , / Vy;---,;-.*..-, (SohidDame) Address: Street and No. PERSONAL AND STATISTICAL PARTICULARS City or Village .... 9 t. AAl M E D IgA L C E R T IFIC A T E OF DISEASE; Se x AGE COLOS - . ' C o u n t r y o r B ir t h 4 * ' 3 1 ` B la c k Single, married, widowed, or divorced (write the word)... Married . O c c u pa t io n (a) Trade, occupation, o p? work (in which disease was ac- q u ire d ).....< t^ M ^ ^ .._ y A . Particular kind of work imsuch trade, __ Diagnosis.. Chief symptoms and conditions. __ -ji&i:--.<3 Date first symptoms appeared------- ..................................L__ \ .C&implicating d:isegges (such culosisj.etc.)... alcoholism, syphilis, tuberf ' - il>ate of entering this occupation.. . . . . / ^ . < 5 ....... . I If gg > Ai gss . -s Q -J Z | < S:2 s! iFlCD E0y ICs sy 5t o *S ^ B S t. Employer's name__ Address.______________ .....:__________....... Employer's business (goods made or work done)__ (b) Previous occupations: .Ncune of occupations ___ Entered -* Left (year) (year) What substance(s) gr condition(s) in your opinion caused this affliction?__ \ Duration (actual, estimated)_. __ (Check which) Additional facts_____ :__ w Previous illnesses, if any, due to occupation: 1 H : Disease or illness -' - 2 Year Date of diagnosis.. . : (Signed). 193.^ T r:........, M. D. /..t - L m ...., 193... - i. Mail to COLLABORATING EPIDEMIOLOGIST, U. S. Public Healtli Service, State Department of Health, Columbus, Ohio. For Instructions See Other Side KE 0016715 N19436 OHIO DEPARTMENT OF HEALTH COOPERATING WITH THE UNITED STATES PUBLIC HEALTH SERVICE COLUM BUS, OH IO INSTRUCTIONS FOR FILLIN G OUT CERTIFICATE Pr e s e n t Oc c u pa t io n .--Precise statement of occupation is very patient may have followed, with the year he entered and the year he important so that the relative healthfulness of various pursuits may peffe' ' ' be known. It is necessary to know both general trade or occupation (for example, -printer) and' also the particular kind of work or branch of the trade (as hand compositor or linotype operator), , P r e v io u s I l l n e s s e s .--This refers either to previous attacks of present disease, or to any other disease, due to occupation. All that is required is the name of each such disease or illness with the year Date of entering this occupation is important to determine how in which it occurred. long the worker may have been exposed to the hazard1before contract ing the disease. ' ' ' ' ' 1 ' M e d ic a l Ce r t if ic a t e .--Only two of the items specified for this require any explanation. In making these reports it is necessary to Employer's name, address, and business are necessary to ascertain distribution of occupational diseases by industries, many trades (e. g., machinists) being common to different industries. consider the possible influence of factors other than occupation as causes of the disease. For this reason any complicating diseases should be noted, such, for example, as alcoholism or syphilis in con nection with arteriosclerosis in cases of lead or other metal poison Pr e v io u s Oc c u pa t io n s need to be known, if possible, because ing. The possible effect of other factors, such as poor hygienic con present illness may be .fhie: to: a former rather th an present occupa ditions in the home, or other personal conditions, must be considered, tion. Give 'imply'th e1'name of each distinct occupation which'the and when discoverable should be noted under additional facts. A N A CT -- To Require the Reporting of Occupat ional Diseases-- ( A s amended February 4 ,1 9 2 0 ) Report of occupational diseases by physicians When and to whom to be made Blanks for report Such reports not evidence Copy of re port to be transmitted to proper official Penalty Be it enacted by the General Assembly of the State of Ohio? Se c t io n 1213-1.---Every physician in this State attending on or called in to visit a patient whom he believes to be suffering from poisoning from! lead, phosphorus, arsenic, brass, wood alcohol, mercury, or their compounds, or from anthrax or from compressed-air illness and ,such other occupational diseases and ailments as the State department of health shall require to be reported, shall within 18 hours from the time of first attending such patient send to the State commissioner of health a report stating: ' ' (a) Name, address, and occupation of patient. (6) Name, address, and business of employer. (c) Nature of disease, (d) Such other information as! may be reasonably required by the State department of health. The reports herein required shall be made oh, cjr in conformity with, the standard schedule blanks hereinafter provided for. The mailing of the report, within the time required, in Stamped envelope addressed to the office Of the State commissioner of health, shall be a compliance with this: section. 1 ' , Se c t io n 1243-2.--The State department of health sfiall prepare and furnish, free of cost, to th physicians included in the preceding seeto^l istandrt schedule blanks' for th ^reports required; undr this act. The form and contents of such blanks shall be determined by the State department of health. - " SEpnoN 1243-3.--Reports made Under this act shall n o t be evidence of th facts therein stated in any action arising out of the disease therein reported. '!j , , SkbtjoN 1|2i4^|b4.r-^l|t shall furthermore be th duty of the State department of health to transmit a copy of all such reports of occupational disease to th proper official having! charg of factory inspection. SkpTpijj '|i^8i-5:^-wlioever:being !a physician bracticing! in the State of Ohio, neglects or refuses to make and transmit to the State commissioner of health any report provided for in Section 1243-1 of the General Code shall be fined not to exceed one hundred dollars or imprisoned for not to exceed 90 days, or both, but no person shall be imprisoned under this section for a first Offens'Ijd't|b! ;^|f|isepiijibn:,h Ways he as and for a first offense unless the affidavit upon which the prosecution is instituted contains the allegation that the offense is a second or repeated offense. : N o t e .--In addition to the diseases or disabilities provided for in Section 1243-1 of the above law, the regulations passed by the Public Health Council on February 27, 1920, provide in Regulation 2 for the reporting of "any disease or disability con tracted as a result of the nature of the person's employment, including the following diseases or disabilities and not excluding others: Anilin poisoning. i Bisulphide-of-carbon poisoning. Naphtha poisoning. Benzinei: (gasoline) poisoning. Carbon-monoxide poisoning. Natural-gas poisoning. Benzol poisoning. ; Dinitrobenzene poisoning. Turpentine poisoning." N o t e .-- A schedule of occupational diseases compensable in Ohio will be sent upon request of the Collaborating Epidemiolo gist, U. S. Public Health Service, State Department of Health, Columbus, Ohio. U. S. GOVERNMENT PRINTING OFFICE 2 -- '1 7 6 2 7 0016716 R. H. M ARKW ITH. M. D. DIRECTOR OF HEALTH JAM ES E. BAUMAN a s s is t a n t D ir e c t o r o f f ic e s : DEPARTMENTS OF STATE BU'LOING LABORATORIES: Oh io S t a t e U n iv e r s it y C a m pu s su bjec t : Ad d r e s s a l l Of f ic ia l C o r r e s po n d e n c e To t h e D ir e c t o r o f He a l t h D epa r t m en t o f H ea l t h COLUMBUS August 7 , 1939 RE; Re porting Occupa tio n al Disease. M em ber s p u b l ic h ea l t h C o u n c il : H. G. SOUTHARD, M. D. W ARREN C . SREID EN B A C H , M. D. W . L JO N ES. D. D. S. A . JU LIU S FREIBER G At t o r n e y a t l a w Robt. A. Kehoe, M.D ., Cin c in n a ti, Ohio . Dear Doctor: Enclose d ple ase fin d tra n s crip t taken from re po rt o f a claim , c la s s i fi e d by the Ohio In d u s tria l Commission as an OCCUPATIONAL DISEASE, the me dical fe ature s o f which were reporte d by you re ce n tly to the In d u s tria l Commission on th e ir re gular fo rm ( s ) . We appare ntly have no re co rd o f th is case in our f i l e s . I . I f you have alre ady reported th is case to the State Dire cto r o f He alth or to the Sta te Department o f He alth under a d iffe r e n t s p e llin g o f the P a tie n t's Name or under anothe r Diagn o s is , ple as e so inform u s , givin g the approximate d ate . The Pa tie n t's Name and Diagnosis are trans cribe d he re w ith as submitted to us by the In d u s tria l Commission. I I . Othe rw ise , ple as e note th a t acco rding to the pro vis io ns o f Se ctio n s 1245-1 to 12 43-5 , General Code o f Ohio , and o f Rule 2 , Ohio San itary Code , the p h ys ician i s re quire d to re po rt any case o f o ccupatio nal d is e a s e , or dis e as e which he BELIEVES to be occu p a tio n a l, to the Sta te Dire cto r o f He alth on blanks prepared fo r th at purpose by the Sta te Department o f He alth . (See re ve rse o f the "Ce r t i fi c a t e o f In d u s tria l o r Occupatio nal Dis e a s e ", e n clo s e d) . The re po rtin g o f an o ccupatio nal dis e as e to the In d u s tria l Commission does no t meet the requirements o f th is s ta tu te . The in formation sought by th is Department i s no t o nly trans m itte d to the ch ie f s tate facto ry in s pe cto r, but is used fo r compiling experience upon which the Goneral Assembly may amend the l i s t o f o ccupatio nal dise ase s sche duled fo r compensation, and p a rtic u la rly in the matte r o f the ADDITION OF OTHER DISEASES. ,, Ple ase f i l l out the remainder o f THE BLANK ENCLOSED, from your i-e cords, make any ne ce ssary co rre ctio n s , and re turn promptly to th is Department. Only t h is ONE form ( c e r t i fi cate ) i s to be re turne d fo r which a franke d onvoTop~o i s e nclo s e d. We s u ggo s t, however, th a t ' you KEEP A COPY fo r your f i l e s . / I I I . An a d d itio n a l supply o f the l a t e s t re vis e d blank c e r t i fi c a t e s i s als o e nclo se d and o ld forms o f th is c e r t i fi c a t e should / be dis carde d. / Yours ve ry t r u l y , O.D.-2 ~ *Fe b ,,, 1939-- 1000 R. H. Markwith., M.D ., Dire ctor o f He alth.