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As a result of Executive Orders No. 1996-1, 1996-2 and 2003-18 and Part
56 of P.A. 368 of 1978, a physician, hospital, clinic or employer must
report known or suspected cases of occupational diseases or workplace
aggravated health conditions to the Michigan Department of Labor
and Economic Growth within 10 days after discovery of the disease or condition
on a report form furnished by the department. This requirement does not
apply to occupational injuries.
This report is furnished by the Department of Labor and Economic Growth
in accordance with Section 5611 (4) of P.A. 368 of 1978 and is required
to be completed and submitted to the Department of Labor and Economic
Growth at the address below for all such cases to fulfill the statutory
mandate prescribed by Section 5611 or Part 56 of the Act.
Instructions for completing report:
General:
Multiple reports on the same individual for the same illness should not
be submitted. The employer should return this form only if the employee
is not referred to a physician, hospital, or clinic. If a physician returns
the form indicating a suspected occupational disease and at a later date
confirms this occupational disease, an updated form confirming their diagnosis
and causative agent should be submitted.
Employers:
If an employer is submitting the form, all questions, with the exception
of those indicated for physicians only, should be completed. The form
should be completed by the employer at the time of onset, discovery, or
suspected occurrence of the employee's illness and returned directly to
Michigan Department of Labor and Economic Growth.
If the employee is referred to a physician, hospital, or clinic, the
employer should complete the forms as stated above and the form should
then accompany the employee for completion by the medical personnel.
Physician, hospital or clinic:
The questions on the form, with the exception of those indicated for physicians
only, may be completed by the employer at the time of onset, discovery,
or suspected occurrence of the employee's illness. The form should then
accompany the employee at the time of referral to a physician, hospital,
or clinic for medical evaluation where the remainder of the form should
be completed and submitted to the Michigan Department of Labor and Economic
Growth. If the employee is seen by the physician without a referral from
the employer, and the physician diagnoses a suspected or confirmed occupational
illness, the entire form is to be completed by the physician and submitted
to the Michigan Department of Labor and Economic Growth.
It is the responsibility of the employer and of physicians, hospitals,
and clinics to ensure that the form is properly completed, signed and
submitted to the Michigan Department of Labor and Economic Growth within
10 days after the onset of the disease, suspected occurrence of the disease,
or a workplace aggravated health condition. The form must be completed
for all suspected or actual occupational diseases or health
conditions aggravated by workplace exposure, including death of the employee
as a result of the disease or health condition aggravated by workplace
exposure.
Completion of this report form does not relieve the employer of the
requirements of notification fatalities and catastrophes and to maintain
records of each recordable occupational injury or illness pursuant to
the requirements of Public Act 154 of 1974, as amended, the Michigan Occupational
Safety and Health Act.
ADDITIONAL REPORT FORMS ARE AVAILABLE FROM THE MICHIGAN
DEARTMENT OF LABOR AND ECONOMIC GROWTH
Michigan Department of Labor and Economic Growth
Michigan Occupational Safety and Health Administration
Management and Technical Services Division
7150 Harris Drive, P.O. Box 30649
Lansing, Michigan 48909-8149
(517) 322-1851
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