Created by gpt-4o-2024-11-20 on 2025-06-14

This image shows a blank form titled "REPORT OF INFECTIOUS DISEASES TO THE STATE BOARD OF HEALTH." It is designed to record cases of infectious diseases as required by Chapter 75, Section 52 of the Revised Laws. The form features columns labeled "Disease," "Name," and "Address" with several horizontal lines for writing information. There is a handwritten note indicating "Malden, Mass," likely where the form was intended for submission. At the bottom, there's a space for the "Signature of Sec’y or Agent of Board of Health," intended for authentication by an authorized official. The layout appears simple and utilitarian, reflecting its purpose as part of public health documentation.

Created by gpt-4o-2024-08-06 on 2025-06-14

This image shows a form titled "REPORT OF INFECTIOUS DISEASES TO THE STATE BOARD OF HEALTH." It is intended for reporting cases of infectious diseases as required by legal provisions. The form includes spaces for the following information:

• The date on which the cases are reported.
• The name of the board of health receiving the report. Specifically, this form is designated for use by the Board of Health of Malden, Massachusetts, as indicated by the handwritten or stamped text "Malden, Mass."

The form also contains a table with three columns labeled "DISEASE," "NAME," and "ADDRESS," where details about individual cases can be entered.

Near the bottom right corner, there is a line for the "Signature of Sec'y or Agent of Board of Health," where the secretary or agent of the board of health can sign.

The form has a date printed at the top, "11-2-'11," which suggests it was printed or used around November 2, 1911.

Created by us.meta.llama3-2-11b-instruct-v1:0 on 2025-06-13

The image depicts a vintage report form titled "REPORT OF INFECTIOUS DISEASES TO THE STATE BOARD OF HEALTH." The form is dated 11-2-'11 and features a header with the title, followed by a subtitle that reads, "As required by the provisions of Chapter 75, Section 52, Revised Laws."

The main body of the form consists of three columns:

• Disease: This column has 10 blank lines for reporting various diseases.
• Name: This column has 10 blank lines for recording the names of individuals affected by the disease.
• Address: This column has 10 blank lines for documenting the addresses of the individuals.

At the bottom of the form, there is a section for the Signature of Sec'y or Agent of Board of Health, accompanied by a dotted line for signing.

The form is printed on a light grayish-brown paper with black ink. A stamp in the top-right corner appears to be a postmark, although the text is illegible. The overall design and layout suggest that this form was used in the early 20th century to report infectious diseases to the state board of health.

Created by us.meta.llama3-2-90b-instruct-v1:0 on 2025-06-13

The image presents a vintage report form for infectious diseases, specifically designed for submission to the State Board of Health. The form is dated November 2, 1911, and features a formal layout with clear headings and sections.

Header Section:

• Title: "REPORT OF INFECTIOUS DISEASES TO THE STATE BOARD OF HEALTH."
• Subtitle: "As required by the provisions of Chapter 75, Section 52, Revised Laws."
• Case Reporting Information: "Cases reported on _______________________, to the Board of Health of _______________________."

Main Body:

• Columns:
  • Disease: A column for listing the names of diseases.
  • Name: A column for recording the names of individuals affected by the diseases.
  • Address: A column for noting the addresses of the affected individuals.
• Rows: The form provides multiple rows for entering data, allowing for the reporting of multiple cases.

Footer Section:

• Signature Line: A line for the signature of the Secretary or Agent of the Board of Health, accompanied by the phrase "Signature of Sec'y or Agent of Board of Health."

Additional Details:

• Form Number: The form is identified as "1500" in the top-left corner.
• Date Stamp: A date stamp in the top-right corner reads "11-2-'11," indicating the date the form was created or updated.

Overall, this vintage report form provides a structured format for reporting infectious diseases to the State Board of Health, ensuring that essential information is collected and recorded accurately.

Created by amazon.nova-lite-v1:0 on 2025-06-14

The image shows a document titled "REPORT OF INFECTIOUS DISEASES TO THE STATE BOARD OF HEALTH." The document is dated November 2, 1911, and it includes a table with columns for "DISEASE," "NAME," and "ADDRESS." The table has multiple rows for recording information about cases of infectious diseases. The document also includes a section for the signature of the Secretary or Agent of the Board of Health. The document appears to be a legal or official document, and it is likely used to report cases of infectious diseases to the State Board of Health.

Created by amazon.nova-pro-v1:0 on 2025-06-14

The image is a form titled "REPORT OF INFECTIOUS DISEASES TO THE STATE BOARD OF HEALTH." It is dated November 2, 1911, and numbered 1500. The form is designed to report cases of infectious diseases as mandated by Chapter 75, Section 52, Revised Laws. The form is addressed to the Board of Health of Maiden, as indicated by a stamp in the upper right corner.

The form has a structured layout with three columns. The first column is labeled "DISEASE," the second column is labeled "NAME," and the third column is labeled "ADDRESS." Each column has multiple rows to accommodate multiple entries, but all rows are currently blank, indicating that no cases have been reported on this form yet.

At the bottom of the form, there is a space designated for the "Signature of Sec'y or Agent of Board of Health," which is also blank, suggesting that the form has not been signed or submitted.

The form is printed on paper with a beige background, and the text is in black. The layout is straightforward, with clear headings and ample space for writing. The form appears to be a standard reporting document used by health officials to track and report infectious diseases within a specific jurisdiction.

Created by gemini-2.0-flash on 2025-06-13

Here is a description of the image:

The image is an old form titled "Report of Infectious Diseases to the State Board of Health." It states that it is required by the provisions of Chapter 75, Section 52, Revised Laws. The form includes a section for the "Cases reported on" date, and an area to specify the Board of Health location, which is handwritten as "Malden, Mass." The main body of the form is divided into three columns labeled "DISEASE," "NAME," and "ADDRESS," each with several blank lines for entering data. At the bottom, there is a space for the "Signature of Sec'y or Agent of Board of Health." The top left corner indicates "1500. 11-2-'11," possibly a reference or date.

Created by gemini-2.0-flash-lite on 2025-06-13

This is a vintage document, a form titled "REPORT OF INFECTIOUS DISEASES TO THE STATE BOARD OF HEALTH." It's designed to report cases of infectious diseases, as mandated by Chapter 75, Section 52 of the Revised Laws.

The form features several key elements:

• Header: It starts with a date ("1500. 11-2-'11").
• Title: "REPORT OF INFECTIOUS DISEASES TO THE STATE BOARD OF HEALTH".
• Instruction: "As required by the provisions of Chapter 75, Section 52, Revised Laws."
• Fields: There are several fields to fill out:
  • "Cases reported on..." (where the date of the cases is recorded).
  • Three columns to fill in details: "DISEASE," "NAME," and "ADDRESS."
  • ". to the Board of Health of ... " (with a stamped/written name in it "Malden, Mass".
• Signature line: "Signature of Sec'y or Agent of Board of Health..." at the bottom for the official's signature.

The document's overall look is a pale, textured paper, giving it an antique feel. It is a historical form used for public health reporting, possibly from the early 20th century.

Created by us.mistral.pixtral-large-2502-v1:0 on 2025-06-14

The image is a historical form titled "Report of Infectious Diseases to the State Board of Health." This form is mandated by the provisions of Chapter 75, Section 52, of the Revised Laws. The form is designed to report cases of infectious diseases to the Board of Health.

The form is divided into three columns:

1. Disease: This column is intended for specifying the type of infectious disease being reported.
2. Name: This column is for the name of the individual affected by the disease.
3. Address: This column is for the address of the individual.

At the bottom of the form, there is a space designated for the "Signature of Sec'y or Agent of Board of Health," indicating that the form must be signed by an authorized representative of the Board of Health.

The form appears to be dated November 2, 1911, as indicated by the date "11-2-'11" at the top left corner. The name of the location, "Holden, Mass," is partially visible, suggesting that this form was used in Holden, Massachusetts.