Section 12:

12. Any further particulars: ............................................................................... ................................................................................................................ ................................................................................................................ I certify that to the best of my knowledge that the information given above is correct. Date ............................. Name: ................................................ Status ........................... Signature ............................................ Note: *Delete whichever is not applicable. FOURTEENTH SCHEDULE [Sections 2, 19, 77 and 86] LIST OF NOTIFIABLE OCCUPATIONAL DISEASES