Australian Mesothelioma Register Report 2002 - Safe Work Australia

APPENDIX BNATIONAL OCCUPATIONAL HEALTH AND SAFETY COMMISSIONAUSTRALIAN MESOTHELIOMA REGISTER NOTIFICATION__________________________________________________________________________Please direct all correspondence to:The RegistrarAustralian Mesothelioma Register, National Occupational Health and SafetyCommission, GPO Box 1577 Canberra ACT 2600 Telephone: (02) 6279 1005Patient details - please supply ALL available informationSURNAME: ................................. FIRST NAMES: ..................................................................ADDRESS:..................................................................................................................................STATE: ………POSTCODE: ………GENDER: M / F DATE OF BIRTH: / /IF DECEASED, DATE OF DEATH: / / PLACE OF DEATH: ..........………DATE OF INITIAL DIAGNOSIS: Month ................ Year: ..................HISTOLOGICAL: YES / NOHOSPITAL DIAGNOSED: ........................ PRIMARY SITE: .................................................CLINICIAN'S NAME: ..................NAME OF LOCAL GP: ………………………………………….ADDRESS: ................................ ADDRESS: ……………………………………………………….Please describe briefly main occupation(s) of patient's worklife.OCCUPATIONYEARINDUSTRY1. ..................................................... 1. .................................................. 19 - 192. ..................................................... 2. .................................................. 19 - 193. ..................................................... 3. .................................................. 19 - 19KNOWN ASBESTOS EXPOSURE: YES / NOIf "YES" please indicate circumstances and duration:.....................................................................................................Details of person completing this form.NAME: ………………………………………… SIGNATURE: ………………………………………ADDRESS: …………………………………… DATE: ..............................................................Please circle the ap propriate category: CLINICIAN PATHOLOGIST CANCERREGISTRY MEDICAL RECORDS ADMINDUST DISEASES BOARD OTHER:----------------------------------------------------------------------------------------------------------------------------Office Use OnlyDate Received:REGISTRATION NO:29