10- 144 C.M.R. ch. 254, § 4
The following information shall be provided with each occupational disease report. (Information may be reported by phone using the Bureau of Health's toll free number 1-800-821-5821, on Department supplied forms, or by writing to the Occupational Disease Program, Maine Bureau of Health, Division of Disease Control, State House Station 11, Augusta, Maine, 04333.)
- Name and phone number of physician/hospital/person making the report
- Name of disease (illness or injury diagnosis)
- Causative agent or mode of injury
- Date of diagnosis
- Attending physician
- Patient's name
- Patient's residence
- Social Security Number
- Mailing address of patient
- Birthdate
- Sex
- Race
- Occupation
- Industry
- Employer name and address
- Any factor known to the physician which is suspected of being a contributing factor to the disease, including, but not limited to, whether or nor the person smokes and, if so, the frequency of smoking.
10- 144 C.M.R. ch. 254, § 4