New Jersey Department of Health

Consumer, Environmental and Occupational Health Service

PO Box 369

Trenton, NJ 08625-0369	OCCUPATIONAL AND ENVIRONMENTAL

DISEASE, INJURY, OR POISONING REPORT

BY HEALTH CARE PROVIDER
INSTRUCTIONS: N.J.A.C. 8:58-1.5 requires a health care provider who diagnoses a person as having a disease, injury or poisoning listed therein to complete the Occupational and Environmental Disease, Injury, or Poisoning Report by Health Care Provider form with respect to the patient and submit the completed form to the Occupational Health Surveillance Unit within 30 days of making the diagnosis. All information MUST be completed. Mail complete report to above address or fax to (609) 292-5677. See Additional Information sheet for clarification.
Date of Report

____ / ____ / ________
SECTION I - PATIENT INFORMATION
Name of Patient (Print)

Date of Birth

____ / ____ / ________
Street Address

Age (If DOB Unavailable)

City

State

Zip Code

Home Telephone Number

( )
Sex

Male Female	Race

White	American Indian/Alaskan Native	Other

Black	Asian/Pacific Islander	Hispanic Origin

Yes No Unknown
SECTION II - DIAGNOSTIC INFORMATION
Date of Onset of Disease, Injury, or Poisoning

____/____/________	Diagnosis

Asbestosis

Asthma, Suspected, Work-Related

Asthma, Confirmed, Work-Related

Hypersensitivity Pneumonitis

Silicosis

Unspecified/Other Pneumoconiosis

Other Occupational Disease, Specify: _____________

Work-Related:

Carpal Tunnel Syndrome

Fatal Injury

Injury in Minors (Under Age 18)

Unspecified Contact Dermatitis (Occupational)

Poisonings:

Arsenic (Complete Section III)

Cadmium (Complete Section III)

Lead (Complete Section III)

Mercury (Complete Section III)

Pesticide

Other Substance or Toxin Unspecified, Work-Related
Date of First Diagnosis

____/____/________
SECTION III - HEAVY METAL TOXICITY
Sample Type	ARSENIC	CADMIUM	LEAD (16 Years of Age or Older)	MERCURY
Reportable

Level	Value

(with Unit)	Reportable

Level	Value

(with Unit)	Reportable

Level	Value

(with Unit)	Reportable

Level	Value

(with Unit)
BLOOD	> .07 (g/mL	> 5 (g/L

Whole Blood	> 5 (g/dL	> 2.8 (g/dL
URINE	> 100 (g/L	> 3 (g/gram creatinine	> 32 (g/L	> 20 (g/L
Name of Testing Laboratory, if Applicable

Telephone Number

( )
Street Address

Date Sample Taken

____ / ____ / ________
City

State

Zip Code

Date Sample Analyzed

____ / ____ / ________
SECTION IV - PLACE OF EXPOSURE / INJURY / ILLNESS
Workplace at which Exposure, Injury or Illness Occurred

Street Address

City

State

Zip Code

Job Title or Type of Work Performed by Patient

Dates of Employment

From:

To:
Patient-Reported Cause of Symptoms

Is Patient still employed at workplace?

Yes No Unknown
SECTION V - HEALTH CARE PROVIDER INFORMATION
Name of Health Care Provider (Print)

Telephone Number

( )
Facility Name

Facility Address

City

State

Zip Code

Comments by Health Care Provider (if any)

OCC-31

DEC 16

OCC-31, Occupational Disease, Injury, or Poisoning Report by Health Care Providers

occupational health service, occupational disease report, occupational injury, poisoning, physician, advanced practice nurses, OCC-31, OCC

ewhite

2015-09-18

NJDOH