W.CL. 22
FIRST MEDICAL REPORT IN RESPECT OF AN OCCUPATIONAL DISEASE
COMPENSATION FOR OCCUPATIONAL DISEASES AND INJURIES ACT, 1993 (ACT No. 130 OF 1993)
	(Previously Workmen's Compensation Act, 1941)
	[Section 74(1)—Commissioner's rules, forms and particulars—Annexure 19]
Claim Number  ……………………
Employee: First and LAST Names
										Name SURNAME
Address	
											
Name of employer	
											
Address	
											
Date of diagnosis										

1. Date of first consultation
											
2. Diagnosis or nature of disease
											
3. Indicate the causative substance or work-process

											

											

4. State the positive aspects from the anamnesis and/or clinical examination supporting the diagnosis (reports of all special investigations must be submitted)

1. ... has worked at this company for ... years					
2. The condition was absent 							
3. The condition started in the employ / was aggravated by 			
4. The condition is proven by							
5. The condition is listed								
											
5. Is the employee unfit to work? 								YES/NO

6. Does the employee suffer from any other disease?						YES/NO
lf so, please specify
											
Account in respect of consultation and/or procedure(s): 	Your Account No:			
							PR No:		0123456789
Description of service	Place and dates of treatment or visits	Item of Tariff	R	C	

					

I certify that I have by examination of the employee satisfied myself of above-mentioned facts.

Date (important)					Medical practitioner signature
Name (printed):				Dr Professor Work, L.E.T.T.E.R.S
Registered address:			12 Avenue Street, Town City, 0123

AII questions must be answered in full. Full motivation of diagnosis will prevent unnecessary correspondence and delays in adjudication of the claim. The form must be forwarded to the employer of the patient within 14 days after the first consultation.

W.CL. 26
FINAL/PROGRESS MEDICAL REPORT IN RESPECT OF AN OCCUPATIONAL DISEASE
COMPENSATION FOR OCCUPATIONAL DISEASES AND INJURIES ACT, 1993 (ACT No. 130 OF 1993)
	(Previously Workmen's Compensation Act, 1941)
	[Section 74(2)—Commissioner's rules, forms and particulars—Annexure 20]
Claim Number  ……………………
Employee: First and LAST Names
											
Address	
											
Name of employer	
											
Address	
											
Date of diagnosis										

1. From what date has the employee been fit for his/her work?					
												
or Since what date has the employee been fit for work in the open labour market?

2. (a) Was the employee required to change his/her occupation following medical advice?		YES/NO 	
	(b) If so, please give the reason								

3. (a) Has there been any permanent loss of function resulting from the occupational disease? 	YES/NO
	(b) If so, give a detailed description thereof substantiated by special examinations where necessary

												

4 (a) Has the employee's condition become stabilised? 					YES/NO
(b) If so, describe in detail any permanent anatomical defect and/or impairment of functions of the occupational disease
The condition is (diagnosis)								
The condition is ? permanent,								
			? progressive,							
				? is amenable to treatment					
This will require? regular prescriptions; ? doctor visits; ? hospital visits	

Account in respect of consultation and/or procedure(s): 	Your Account No:			
							PR No:		0123456789
Description of service	Place and dates of treatment or visits	Item of Tariff	R	c	

					
I certify that I have by examination, satisfied myself that the condition of the employee is the result of the occupational disease as described above.

Date (important)					Medical practitioner signature
Name (printed):				Dr Professor Work, L.E.T.T.E.R.S
Registered address:			12 Avenue Street, Town City, 0123

NB.: Progress reports must be submitted on a monthly basis to the Compensation Commissioner or mutual association or employer individually liably as the case may be until the employee’s condition has become stabilised -when a final medical report should be submitted.