APPENDIX D. 



BLANK FOR REPORTING EXISTENCE OF INFECTIOUS 

 DISEASES. 



Dkpartment of Health, the City of New York. 



Report of Dairymen to be Filled Out and Delivered at Creamery p;verv 

 Saturday Morning. 



Date 

 To the Manager : 



Creamery. 

 -Town. 



. . State. 



vSir: 



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

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

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

 honor. 



Owner of Farm 



Operator of Dairy.. 



Location 



No. of Persons in F^amily No. of Persons in Hoiiseholds of 



JFann 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. Dise.\sk. Attending Physician. 



Respectfully, 



• The following infectious diseases are to be reported : 

 Measles Varicella (Chicken Pox) Ensipelas 



Rubella (German Measles) Diphtheria Whooping Cough 



Scarlet Fever Typhoid Fever Epidemic Cerebro-Spinal Meningitis 



Small Pox Tuberculasi.s (Coti.sumption) 



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



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