Form BI100OAE
About you
01. First name
About you
02. Last name
About you
03. National Insurance (N I) number
About you
04. Are you claiming for: Occupational asthma (prescribed disease D7), or Allergic rhinitis (prescribed disease D4)
Options: Occupational asthma (prescribed disease D7); Allergic rhinitis (prescribed disease D4)
About your employment or your approved training scheme or course
05a. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05a. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05b. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05b. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05c. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05c. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05d. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05d. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05e. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05e. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05f. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05f. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05g. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05g. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05h. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05h. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05i. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05i. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05j. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05j. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05k. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05k. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05l. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05l. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05m. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05m. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05n. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05n. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05o. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05o. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05p. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05p. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05q. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05q. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05r. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05r. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05s. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05s. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05t. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05t. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05u. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05u. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05v. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05v. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05w. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05w. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
05x. In any of the jobs or training schemes c: fumes or dusts arising from you have told us about on form the manufacture, transport or use of hardening agents (including epoxy resin curing agents) based on phthalic anhydride, tetrachlorophthalic anhydride, trimellitic anhydride or triethylenetetramine
Options: Yes; No
About your employment or your approved training scheme or course
05x. Who was your employer or training provider at the date of exposure
About your employment or your approved training scheme or course
06. Do you think your asthma or allergic rhinitis was caused by any other substance you were exposed to at work or whilst on an approved training scheme?
Options: Yes; No
About your employment or your approved training scheme or course
06. What was the substance? Please be as precise as possible. General terms such as smoke, fumes or dust will not be good enough
About your employment or your approved training scheme or course
06. Who was your employer or training provider at the date of exposure?