The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Ws7yDNZNtoseSDBf4ZTwR4jLYbntuh7SQJ96MiNC2KrsXrLoDsZPWV7Qt2KD32QLv934Un9fIhw4ubMcHxmyPp9Euh9

Massachusetts Department of Public Health (DPH) - Confidential Report of Occupational Disease and Injury

In accordance with 105 C.M.R. 300.000, healthcare providers must report any patient with a suspected or confirmed diagnosis of any disease or injury listed below that is believed to have been caused or aggravated by factors in the individual's workplace. Cases should be reported within ten days of diagnosis or identification.

Reporting Source Information
Reporting Date:
Reporting Healthcare Provider Name:
First:	Middile:	Last:
Name of Institution/Clinic:
Address:
City/Town:	State:	Zip Code:
Phone:		Medical Specialty:

Patient Information
Patient Name:
First:	Middle:	Last:
Address:
City/Town:	State:	Zip Code:
Home/Cell number:	Patient Date of Birth:	Sex:
Race (check all that apply):		Hispanic/Latino:
		Preferred Language:
Occupation or type of work performed by patient:
Name of company where exposure/injury occurred:
Type of business or industry:
Is patient still employed at company?

Occupational Diagnosis
Is the diagnosis:		Date of Diagnosis:

* must provide value

New-onset asthma Work-aggravated asthma Reactive Airways Dysfunction Syndrome (RADS)

reset

Suspected Agent(s):

* must provide value

Specify other work-related lung disease:

* must provide value

Specify serious work-related injury to persons < 18-years-old:

* must provide value

Specify acute chemical poisoning:

* must provide value

Specify heavy metal absorption:

* must provide value

Describe outbreak or cluster:

* must provide value

Remarks:
See below for reporting guidelines

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