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34
NOTIFICATION FORM.
BOROUGH OF RICHMOND (SURREY).
INFECTIOUS DISEASES. NOTIFICATION FORM FOR SCHOOLS.
Measles, Whooping Cough, Chicken Pox, Mumps.
If a child is suffering from any of the above diseases, or if,
though not himself affected some other occupant of the
same house is, this Form should be at once filled up and
forwarded to the Medical Officer of Health.
Date when reNames
of Addresses of ported to Supposed ,
•Scholars. Scholars. attendance at Medical officer nature of Illness Remarks.
Sch°o1 ot Health.
Name of School
Department
Teacher's Signature
Date