Document xzg79bqvkBXJEB2Q6oJ34zj4Q

WRITE P L A IN L Y W ITH INK-- THIS IS A PERMANENT RECORD N. B.--Every Item o f information should be carefully supplied. The exact statement o f OCCUPATION is very Important. Physicians should state D I AG NOSIS In plain terms. See Instructions on bach o f certificate. ^ /7 Jr? : 7 ' Form 9436 \ U. E.-TREASURY DEPARTMENT MSflPtiBIilC. HEAt.ta-:SE&YfCE s* (April 1938) THE UNITED STATES PUBLIC HEALTH SERVICE COOPERATING WITH i :7. ; > OHIO DEPARTMENT OP HEALTH % I'Wf ' CERTIFICATE OF INDUSTRIAL ATIONAL DISEASE ;:c,i./.M- \ Name of Patient (Last name) / / (First name) Jv-- . (S^cmid name) Village Oineinnatl* ^io Address: Street and No. ....City or ........... ISil p e r s o n a l a n d s t a t is t ic a l p a r t ic u l ar s MEDICAL CERTIFICATE OF DISEASE "pASSix ' Ac k Co l o b ' 31 ` pledc-j. Single, married, widowed, or divorced (write the word)... Co u n t r y or Bib t h K&rried Oc c u p a t io n (a) Trade, occupation, op? work (in, which disease was acquired)..,^^^^^2^_______________________ L. Particular kind of work imsuch trade, Chief symptoms and conditions. .44* Date first symptoms appeared, i Gfomplieating diseases (such ap alcoholism, ^ culosis.^etc.) __ syphilis, tuber- ^I)ate of entering this occupation....... Employer's name___ZS Address._______________ _______________:......._____ _____ Employer's business (goods made or work done)______ ...____ What substance(s) or condition(s) in your opinion, caused this affliction?_______________________________________________, Ss (b) Previous occupations: . Name of occupations __ Entered Cyear) Left (year) Duration (actual, estimated)_. __ (Check which) Additional facts______:__ Previous illnesses, if any, due to occupation: Disease or illness ' - Year Date of diagnosis. , (Signed). --Z 193... Mail to COLLABORATING EPIDEMIOLOGIST, U. S. Public Health Service, Slate Department of Health, Columbus, Ohio. r--------- jr-------------- 193.^ .....^ For Instruction* See Other Side HE 0016715 N19436 OHIO DEPARTMENT OF HEALTH COOPERATING WITH THE UNITED STATES PUBLIC HEALTH SERVICE COLUMBUS, OHIO INSTRUCTIONS FOR FILLING OUT CERTIFICATE Pr es en t Oc c u p at io n .--Precise statement of occupation is very important so that the relative healthfulness of various pursuits may be known. It is necessary to know both general trade or occupation (for example, -printer) and' tlso the particular kind of work or branch of the trade (as hand compositor or linotipe operator): Date of entering this occupation is important to determine how long the worker may have been exposed to the hazard1 before contract ing the disease. Employer's name, address, and bvsiness are necessary to ascertain distribution of occupational diseases by industries, many trades (e. g., machinists) being common to different industries. Pr e v io u s Oc c u p a t io n s need to be known, if possible, because present .illness may be due to a former rather than present occupa tion. Give: dimply the1'name of each distinct occupation which'the patient may have followed, with the year he entered and the year he piaffe" Pr e v io u s Il l n e s s es .--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 in which it occurred. Me 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 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 w'ith arteriosclerosis in cases of lead or other metal poison ing. The possible effect of other factors, such as poor hygienic con ditions in the home, or other personal conditions, must be considered, and when discoverable should be noted under additional facts. AN ACT--To RequireThe Reporting of Occupational Diseases--(As amended February 4,1920) 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 ofthe State of Ohio: Sec t io n 1243-1.'--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 48 hours from the time of first attending such patient send tp 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, c^r in conformity with, the standard schedule blanks hereinafter provided for. The mailing of the report, within the time required, in a stamped envelope addressed to the office Of the State commissioner of health, shall be a compliance with this: section. preceding :---- r__. ___ ------ ------------ ----- be determined by the State department of health, j Sf .c t io n 1243-3.--Reports made under this act shall not be evidence of the facts therein stated in any action arising out of tiic disease therein reported. Sec t io n ;,l2!4|jr4.r-Jl|t shall furthermore be the duty of the State department of health to transmit a copy of all such reports of occupational disease |o the proper official having! charge of factory inspection. Sec t io n 1243-5.--Whoever! being a physician practicing! 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; oi| imprisoned fori hot fd exceed 90 days, dr both, but noiperson shall be imprisoned under this section for a first offense and the prosecution shall ahvays be 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. No 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 thq following diseases or disabilities and not excluding others: Amlin poisoning. Bisulphide-of-carbon poisoning. Naphtha poisoning. Benzine (gasoline) poisoning. Carbon-monoxide poisoning. Natural-gas poisoning. Benzol poisoning. : _Dinitr_o_b_e_n_z__e_n_e__p_o_is_o_n__ingo. Turpentine poisoning." No t e.--A schedulei of occupational diseases compensable in Ohio will be sent upon request of the Collaborating Epidemiolo gist, U. 8. Public Health Service, State Department of Health, Columbus, Ohio. U. S. GOVERNMENT PRINTING OFFICE 2-----17627 CT*3fe HE 0016716 R. H. MARKWITH. M. D. Dir e c t o r o f h e a l t h JAMES E. BAUMAN as s is t an t d ir ec t o r o p f 'c e s : De p a r t me n t s o p St a t e b u il o in g La b o r a t o r ie s : Oh io St a t e Un iv e r s it y Ca mp u s s u bj ec t : Ad d r e s s a l l Op p s c ia l Co r r e s p o n d e n c e To t h e d ir e c t o r o p He a l t h De p a r t me n t o f He a l t h COLUMBUS August 7, 1939 RE; Reporting Occupa tional Disease. MEMBERS PUBLIC HEALTH COUNCIL! H. G. SOUTHARD. M. D. WARREN C. 3REIDENBACH, M. D. W. I. JONES. D. D. S. A. JULIUS FREIBERG At t o r n e y a t l a w Robt. A. Kehoe, M.D*, Cincinnati, Ohio. Dear Doctor: Enclosed please find transcript taken from report of a claim, classified by the Ohio Industrial Commission as an OCCUPATIONAL DISEASE, the medical features of which were reported by you recently to the Industrial Commission on their regular form(s). We apparently have no record of this case in our files. I. If you have already reported this case to the State Director of Health or to the State Department of Health under a different spelling of the Patient's Hame or under another Diagnosis, please so inform us, giving the approximate date. The Patient's Hame and Diagnosis are transcribed herewith as submitted to us by the Industrial Commission. II. Otherwise, please note that according to the provisions of Sections 1245-1 to 1243-5, General Code of Ohio, and of Pule 2, Ohio Sanitary Code, the physician is required to report any case of occupational disease, or disease which he BELIEVES to be occu pational, to the State Director of Health on blanks prepared for that purpose by the State Department of Health. (See reverse of the "Certificate of Industrial or Occupational Disease", enclosed). The reporting of an occupational disease to the Industrial Commission does not meet the requirements of this statute. The in formation sought by this Department is not only transmitted to the chief state factory inspector, but is used for compiling experience upon which the Goneral Assembly may amend the list of occupational diseases scheduled for compensation, and particularly in the matter of the ADDITION OP OTHER DISEASES . Please fill out the remainder of THE BLAHK ENCLOSED, from your i-ecords, make any necessary corrections, and return promptly to this Department* Only this OHE form (certificate) is to be returned for which a franked envelope is enclosed^We suggost, however, that you KEEP A COPY for your files. III. An additional supply of the latest revised blank certificates is also enclosed and old forms of this certificate should / / bo discarded. Yours very truly. O.D.-2aFeb, 1939--1000 v,, R. H. Markwith, M.D., Director of Health. N19436.01