Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 254 - OCCUPATIONAL DISEASE REPORTING RULES AND REGULATIONS
Section 144-254-4 - REQUIRED DATA

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.