Schedule 11

ELEVENTH SCHEDULESection 60(3).Notice of Patient Suffering from Industrial Diseases(This notice shall be completed by the occupier of factory pursuant to section 60(3) of the Factories Act, 1973, and forwarded to the Chief Inspector of Factories, Ministry of Labour, Havelock Road, Singapore 1).Name of OccupierOffice AddressFactory AddressNature of BusinessParticulars of patient who has contracted the industrial disease:LIST OF NOTIFIABLE INDUSTRIAL DISEASES: —ANILINE POISONINGNameANTHRAXARSENICAL POISONINGNRIC No.ASBESTOSISAddressBERYLLIUM POISONINGBYSSINOSISCADMIUM POISONINGSexAgeCARBON BISULPHIDE POISONINGCHROME ULCERATIONOccupationCHRONIC BENZENE POISONINGCOMPRESSED AIR ILLNESSEPITHELIOMATOUS ULCERATIONHow long employed prior to the date of contracting the industrial diseaseINDUSTRIAL DERMATITISLEAD POISONINGMANGANESE POISONINGName of industrial disease diagnosed by the doctorMERCURIAL POISONINGMESOTHELIOMANOISE INDUCED DEAFNESSPHOSPHOROUS POISONINGName of doctor who makes the diagnosisSILICOSISTOXIC ANAEMIATOXIC JAUNDICEName and Address of Hospital/Clinic DateSignature of Occupier of Factory.”.