Reports must be sent to the New York State Department of Health within 10 days of diagnosis (State Sanitary Code, Part 22.4)
Occupational Lung Disease Registry
Reporting Form
New York State Department of Health
Confidential Case Report
Bureau of Occupational Health and Injury Prevention
Date of Report
Type or print clearly using blue or black ink.
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Patient Information:
Last Name
Address
Street
Home Phone Number
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Race
 White
First
 Black/ African
American
MI
City
Date of Birth
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State
Gender
 Male
 American Indian/
Alaskan Eskimo
Suspected Diagnosis
Occupational Asthma
Reactive Airways Dysfunction
Syndrome
Hypersensitivity Pneumonitis
 Farmers Lung Disease
 Bird Handlers Lung Disease
 Inhalation Fevers
 Metal Fume Fever
 Polymer Fume Fever
 Organic Dust Toxic Syndrome
Irritant (e.g. smoke, chlorine, gas, etc.)
(ODTS)
 Toxic
 Silo Filler’s Lung Disease
 Metal-Induced Disease
 Berylliosis
 Hard Metal Disease
 Pneumoconiosis
 Asbestosis
 Byssinosis
 Coal Workers Lung Disease
 Silicosis
 Pleural Disorders
 Asbestos-related Pleural Plaques
 Mesothelioma
 Pulmonary Fibrosis, Undet. Etiology
 Chronic Bronchitis
 Lung Cancer
 Other,
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DOH 384 (01/13)
FIPS
Social Security Number
 Female
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Hispanic
 Asian/ Pacific
Islander
Employer (company name) at Time of Suspected Exposure
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Zip Code
 Other
Suspected Relevant Occupation
Confirmed
Suspected
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COC Code
Date of
Suspected Agent AOEC
Diagnosis
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Reports must be sent to the New York State Department of Health within 10 days of diagnosis (State Sanitary Code, Part 22.4) Page 1 of 2
Reports must be sent to the New York State Department of Health within 10 days of diagnosis (State Sanitary Code, Part 22.4)
Related Diagnostic Test
Performed
 Pulmonary Function Test
 Peak Flow
 Challenge Test
 Bronchoscopy
 X-ray
 CT Scan
 Serology
 Cytology
 Allergy Testing
 Lung Biopsy
 Other, _______________
Test Results
Normal Abnormal Pending
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Primary Care or Attending Physician:
Name
Address
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Date of Test
Location Where Performed
Name
Address
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City
State
Zip
Phone
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Reporting Hospital:
Case is non-occupational 
Comments:
To request additional forms please check the box below and indicate how many forms are needed or visit
www.health.ny.gov/nysdoh/lung/lung.htm to download the form.
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You may also report an occupational lung disease by calling 1-866-807-2130 or 1-518-402-7900
Please send/fax completed form to:
New York State Department of Health
Bureau of Occupational Health and Injury Prevention
Occupational Lung Disease Registry
Corning Tower, Room 1325
Empire State Plaza
Albany, NY 12237
Fax: (518) 402-7909
Reports must be sent to the New York State Department of Health within 10 days of diagnosis (State Sanitary Code, Part 22.4) Page 2 of 2