UNIVERSITY OF CAPE TOWN
WorkHealth Occupational Diseases Clinic
E16; Groote Schuur Hospital; OBSERVATORY; 7925

ADDRESS

Dear Employer

	Name SURNAME
	Born 
	GSH # 
	Diagnosis:

1. Your employee … has been diagnosed with an occupational disease of …
2. The condition requires … and … which has been arranged. / The condition is progressive, and no specific treatment is possible.
3. Please complete the details in the forms WCL 14 and WCL 22.
4. Please complete an Employer’s Report (WCL 1).
5. Please then post the medical report, together with all the forms - to the address below:

The Compensation Commissioner, PO. Box 955, Pretoria, 0001.

Sincerely

Dr Professor Work, L.E.T.T.E.R.S
Public Health Medicine Specialist
2003
Cell: ; Tel: ; Fax: 

Medical report

Name SURNAME
Born dd.mm.yyyy
GSH # 
Diagnosis: 

History

Work History
	Employer	Job	Duration	+/- Year	
0.					
1.					
2.					
3.					
4.					

Exposure

Effects

Examination

Tests
Chest X-Ray:
Spirometry: 
	pre	post	predicted	
FEV1 in ml				
FVC in ml				
FEV1/FVC %				

Assessment

Plan
1. 
2. 
3. 
4. 
5. 

Claim Number ………………

NOTICE OF AN OCCUPATIONAL DISEASE AND CLAIM FOR COMPENSATION
COMPENSATION FOR OCCUPATIONAL DISEASES AND INJURIES ACT, 1993 (ACT No. 130 OF 1993)
	(Previously Workmen's Compensation Act, 1941)
	[Section 68 (1)—Commissioner's rules, forms and particulars—Annexure 18]

This form must be completed by or on behalf of the injured employee/ dependents and sent to the Compensation Commissioner, PO Box 955, Pretoria 0001

(BLOCK LETTERS)
1.	EMPLOYEE
First and LAST Names	Name SURNAME								

Identity Number					Personnel Number				

Residential address										

Date of birth 19YY.MM.dd		Sex	Female/Male	Married or Single 		Married/Single

Occupation											

2.	EMPLOYER
Name of employer in whose service the disease was contracted					
	
Address												

Name of present or last employer									

3.	NATURE OF DUTIES PERFORMED

Describe the manner in which the employee allegedly contracted the disease (mention the causative agents or process):

												

4.	(i)	Date on which the disease was reported to the employer				
						
	(ii)	Date of first consultation with a doctor							

	(iii)	Name and address of doctor	Dr Professor Work
						12 Avenue Street, Town City, 0123

iv)	Date of which the disease was diagnosed							

W CL 14										Please also complete reverse side

5.	THE EMPLOYEE’S EARNINGS AT THE TIME OF DIAGNOSIS OF THE DISEASE OR WHEN LAST EMPLOYED

	Per week
R	Per month
R	
Gross cash earnings
(including average overtime and/or commission of a regular nature) …………………….			

Allowance of a regular nature …………………………………………………………………			

(a) Bonuses (e.g. 13th cheque) ………………………………………………………………			

(b) Other (specify) ……………………………………………………………………………...			

……………………………………………………………………………………………………			

Cash value of quarters ………………………………………………………………………..			

Cash value of food ……………………………………………………………………………..			

I certify that the information in this form is to the best of my knowledge correct.

DATE:																			Signature of employee or person acting on his/her behalf