APPENDIX D. 



BLANK FOR REPORTING EXISTENCE OF INFECTIOUS 



DISEASES. 



DEPARTMENT OF HEAI/TH, THE CITY OF NEW YORK. 



Report of Dairymen to be Filled Out and Delivered at Creamery Every 

 Saturday Morning. 



Date.... 

 To the Manager : 



..Creamery. 

 .Town. 

 ...State. 

 Sir: 



In accordance with the requirements of the Board of Health of the 

 Department of Health of the City of New York in relation to infectious 

 disease* among milk handlers, I make the following 1 statement upon my 

 honor. 



Owner of Farm... 

 Operator of Dairy.... 

 Location 



No. of Persons in Family No. of Persons in Households of 



Farm Hands.. No. of "Summer Boarders" 



There are no cases of infectious diseases among any of the above men- 

 tioned persons, except as hereinafter stated. 



NAME OF PATIENT. DISEASE. ATTENDING PHYSICIAN. 



Respectfully, 



The following infectious diseases are to be reported : 



Measles Varicella (Chicken Pox) Erysipelas 



Rubella (German Measles) Diphtheria Whoopinyr Coiitfh 



vScarlet Fever Typhoid Fever Epidemic Cerebro-Spinal Meningitis 



Small Pox Tuberculosis (Consumption) 



(This report to be kept on file in creamery at least six months. ) 



