EMPLOYER DATA FOR VERIFICATION AND CERTIFICATION OF RIGHTS

MEXICAN SOCIAL SECURITY INSTITUTE 1) NAME OF THE EMPLOYER OR COMPANY NAME OF THE COMPANY
DIRECTORATE OF MEDICAL BENEFITS
2) ADDRESS OF THE COMPANY, STREET AND NUMBER

HEALTH CARE NOTICE AND QUALIFICATION OF

COLONY OR FRACTIONATION, DELEGATION OR MUNICIPALITY, CITY AND STATE
IMSS PROBABLE OCCUPATIONAL ILLNESS ST-9
(FOR EXCLUSIVE USE OF HEALTH SERVICES IN
THE JOB) 3) ZIP CODE 4) TELEPHONE (LADA)

5) EMPLOYER REGISTRATION (11 DIGITS)

TO BE FILLED BY HEALTH SERVICES AT WORK

6) SOCIAL SECURITY NUMBER (11 DIGITS) 7) PATERNAL, MATERNAL SURNAME AND FIRST NAME(S)

8) OFFICIAL IDENTIFICATION (SPECIFY) 9) CURP

10) AGE (YEARS) 11) SEX 12) CIVIL STATUS 13) ADDRESS: STREET AND NUMBER COLONY OR FRACTIONATION

M F

DELEGATION OR MUNICIPALITY, CITY AND STATE 14) ZIP CODE 15) TELEPHONE (LADA)

16) ASCRIPTION UMF 17) DELEGATION (IMSS) 18) DATE AND TIME OF THE FIRST CONSULTATION FOR PROBABLE WORK ILLNESS
DAY MONTH YEAR HOUR

19) DETAILED DESCRIPTION OF THE CAUSING AGENTS AND THE TIME OF EXPOSURE TO THEM

20) DESCRIPTION OF THE SYMPTOMATOLOGY, THE TIME OF EVOLUTION, THE LABORATORY AND CABINET STUDIES AND THE INTERCONSULTATIONS

21) NOSOLOGICAL, ETIOLOGICAL AND ANATOMOFUNCTIONAL DIAGNOSIS

22) TREATMENT

23) TEMPORARY DISABILITY IS START DATE OF INITIAL No. FOLIO NUMBER OF DAYS AUTHORIZED 24) PATIENT IS SENT TO THE MEDICAL SERVICE OF
REQUIRED DISABILITY
DAY MONTH YEAR
YEAH NO

25) FULL NAME OF THE DOCTOR TUITION PHYSICIAN'S AUTOGRAPH SIGNATURE 26) MEDICAL UNIT AND DELEGATION (IMSS)

THE INSURED COMPLIANCES WITH ARTICLE 51 THE SOCIAL SECURITY LAW OF OWN LAW CHO AND UNDER PROTEST OF TELLING
DEFAULTS THAT THE DATA AND FACTS SET OUT HERE ARE TRUE TRUTH

WORKER (NAME AND SIGNATURE) RELATIVE OR REPRESENTATIVE (NAME AND SIGNATURE)

ADDRESS AND TELEPHONE OF THE RELATIVE OR

REPRESENTATIVE
COMPLEMENTARY DATA FOR THE CLASSIFICATION OF PROBABLE WORKPLACE ILLNESS (TO BE FILLED IN BY THE COMPANY)
1) NAME OF THE EMPLOYER OR COMPANY NAME OF THE COMPANY 2) ACTIVITY OR TURN
3) EMPLOYER REGISTRATION (11
DIGITS)

4) ADDRESS: STREET AND NUMBER COLONY OR FRACTIONATION

DELEGATION OR MUNICIPALITY, CITY AND STATE POSTAL CODE 5) TELEPHONE (LADA) 6) EMAIL

7) NAME OF WORKER 8) SOCIAL SECURITY NUMBER (11 DIGITS) 9) ADDRESS: STREET AND NUMBER

COLONY OR FRACTIONATION DELEGATION OR MUNICIPALITY, CITY AND STATE 10) ZIP CODE

11) OCCUPATION PERFORMED AT THE TIME OF THE BEGINNING OF THE ILLNESS 12) SENIORITY IN OCCUPATION 13) DAILY SALARY

14) CURRENT WORKING SCHEDULE 15) REGISTRATION (ONLY IF YOU ARE AN IMSS WORKER) 16) BUDGET KEY OF THE IMSS ASSIGNMENT UNIT (ONLY IF
YOU ARE AN IMSS WORKER)

17) DATE OF DIAGNOSIS DAY MONTH YEAR 18) DATE AND TIME WHEN THE WORKER SUSPENDED WORK DAY MONTH YEAR HOUR
OF THE ILLNESS DUE TO THE ILLNESS (ONLY IF THE WORKER HAS BEEN DISABLED)

19) PRECISE DESCRIPTION OF THE CAUSING AGENTS AND THE TIME OF EXPOSURE TO THEM

20) NAME AND POSITION OF THE PERSON IN THE COMPANY WHO TOOK INITIAL KNOWLEDGE OF THE ILLNESS 21) DATE AND TIME OF COMMUNICATION OF THE DISEASE
DAY MONTH YEAR HOUR

22) CLARIFICATIONS AND OBSERVATIONS (COMPLEMENTARY INFORMATION DEEMED RELEVANT TO BE CONSIDERED BY THE HEALTH SERVICES AT WORK OF THE IMSS; IF NECESSARY, ANNEX AN
EXPLANATORY LETTER WITH THE COMPANY'S SIGNATURE AND SEAL)

23) NAME OF THE EMPLOYER OR HIS LEGAL REPRESENTATIVE 24) PLACE AND DATE

25) HANDMADE SIGNATURE OF THE EMPLOYER OR HIS LEGAL REPRESENTATIVE 26) STAMP (IF YOU DO NOT HAVE A STAMP, PUT THE SKIPPER'S AUTOGRAPHIC SIGNATURE)

QUALIFICATION OPINION (FOR EXCLUSIVE USE OF IMSS HEALTH SERVICES AT WORK)

27) NOSOLOGICAL, ETIOLOGICAL AND ANATOMOFUNCTIONAL DIAGNOSES OF THE DISEASE

28) LEGAL BASIS OF THE QUALIFICATION 29) MEDICAL UNIT

30) FULL NAME OF THE DOCTOR WHO FORMULATED THIS 31 IMSS REGISTRATION 32) PLACE AND DATE DAY MONTH YEAR 33) DELEGATION
OPINION

34) IT IS ACCEPTED AS A WORK DISEASE 35) AUTOGRAPH SIGNATURE OF THE QUALIFYING

YEAH NO

LADY) IF YOU DO NOT AGREE WITH THE RATING, YOU MAY DISSATISFIED WITHIN 15 BUSINESS DAYS
WORKER: FOLLOWING THE NOTIFICATION, IN COMPLIANCE WITH ARTICLES 44 AND 294 OF THE SOCIAL SECURITY LAW AND THE CORRESPONDING
REGULATION.
RECEIVED COPY ST-9
DATE:

NAME AND SIGNATURE OF THE WORKER, BENEFICIARY OR REPRESENTATIVE