Section 12, The Workmen's Compensation Citation

Employer's reference number ............................................................................................................. ..Dated this .................................... day of...................................................... 19 ...... . Signature of person giving the notice ............................................................................................... . Address of person givng the notice ............................................................................................... . FOR OFFICIAL USE. 1. Date received ................................................... :.................................................................................................... . 2. Accident No ......................................................................................................................................................... . 3. Industry ................................................................................................................................................................ .. 4. Occupation ............................................................................................................................................................. .. 5. · Classification ........................................................................................................................................................ . 6. Sex ................................................................................................................................................................................ . N otijication of Injuries [Cap. 219 7. Copy of Medical Officer's Report received ............................................................................. . 8. Dependants (in the case of fatal accidents) .................:........................................................... . 9. Interim payments made to worker .............................................................................................. .. 10. Assessment of compensation................................................................................................................. . FoRM No.2. NoTIFICATION oF DEATH. 1. Name of firm or proprietor...................................................................................................................... .. 2. Address of firm ................................................................................................................................................. .. 3. Address and place where death occurred.................................................................................. .. 4. Date and time of death ........................................................................................................................,.... . 5. Name of injured worker ..................................................................................... ,...................................... .. 6. Tribe, chiefdom, home town (village) and address of worker ............................ .. 7. (a) Sex (b) age (c) occupation of person (a) .................. (b) .................. (c) ................ .. 8. Statement by person in charge describing cause and circumstances of death, if known ........................................................................................................................................... .. 9. Was machinery involved, if so, was there any failure of an essential part~ .................................................................................................................................................................... . 10. Employer's reference number .............................................................................................................. . Dated this .......................................... day of............................................................ 19...... . Signature of person giving the notice ............................................................................................ . Address of person giving the notice .................................................................. :........................... .. FOR OF FIOIAL USE. 1. Date received ........................................................................................................................................................ . 2. Accident No ............................................................................................................,............................................ . 3. Industry ................................................................................................................................................................ .. 4. Occupation .............................................................................................................................................................. . 5. Classification ........................................................................................................................................................ . 6. Sex ................................................................................................................................................................................. . 7. Copy of Medical Officer's Report received ............................................................................ .. 8. Dependants .......................................................................................................................................................... .. 9. Interim payments made to worker .............................................................................................. .. 10. Assessment of compensation ................................................................................................................ .. To: FoRM No. 3. REQUEST BY EMPLOYER TO WORKMAN TO SUBMIT HIMSELF FOR MEDICAL ExAMINATION. In reference to your notice given on t}le ........................ day of... ..................... that you have met with an accident causing personal injury, you are hereby required to ?ubmit yourself for examination by Dr ........................................................................................... who 1s the medical practitioner named by me ............................................................ at .............................. on the ........................ day of.............................,.................. l9............ , at ..... ,..... ,..........,......,.....,.....,.....,.....,...... m. 1874 Cap. 219] Workmen's Compensation (if you claim that you are unable or not in a fit state to attend the above medical examination you should inform me immediately). Dated this ........................ day of................................................ , 19...... . Signature. FoRM No. 4. DETAILS OF AGREEMENT AS TO THE AMOUNT OF CoMPENSATION PAYABLE BY THE EMPLOYER. (This form must be completed and forwarded to the Clerk of the Court by the party who desires the agreement to be made an Order of the Court.) 1. Name, address and business of employer........................................................................ 2. (a) Name and address of workman (tribe, chiefdom, home town) ................. . (b) Occupation ......................................................................................................................................... . (Full details of the nature of the work and duties on which the workman was employed at the date of the accident.) (c) Age ....................................................................................................................................................:........ .. (d) Sex ............................................................................................................................................................... (e) Previous Compensation awarded (if any) ........................................................... . 3. (a) Date of accident ............................................................................................................................. . (b) Cause of accident .......................................................................................................................... : (c) Nature and circumstances of injury.............................................................................. (Give full details and state whether incapacity is total or partial, permanent or temporary. If partial, the degree, and, if temporary, the period of incapacity must be given.) 4. Contract of employment................................................................................................................. . The monthly earnings must be stated, specifying the value of food ,fuel or quarters 5. Date of agreement ................................................................................................................................... . 6. Amount of compensation agreed upon and to whom payable ....................... . (Copy of agreement must be given.) 7. (a) Amount payable in a lump sum. .................................................................................... .. (b) Amount and period of periodical payments........................................................ . 8. Any other information ....................................................................................................................... . Signature of Applicant. Sworn before me this .............................. day of...................................................... , 19...... . Commissioner of Oaths. FoRM No.5. APPLICATION FOR ENFORC.ING CLAIM TO CoMPENSATION. (This form must be completed and forwarded to the Clerk of Court, by the workman making application for enforcing his claim to compensation.) 1. Narne of firm or proprietor ........................................................................................................... . 2. Address of firm. ........................................................................................................................................ . 3. Place where accident occurred .................................................................................................... . Notification of Injuries [Cap. 219 1875 ------------------------------------------------------------------ 4. Date and time of accident............................................................................................................... 5. Name of injured worker ................................................................................................................. . 6. Tribe, chiefdom, home town (village) and address of injured worker 7. (a) sex .......................................................................................... (b) age .................................................. . (c) occupation of injured person........................................................................................... .. 8. Nature of injury sustained .......................................................................................................... .. 9. Percentage incapacity or medical report .......................................................................... . 10. Average earnings per month ................................ :....................................................................... . 11. Amount of compensation claimed......................................................................................... . Signature. SCHEDULE B. If payments have been made in respect of an accident by an Employer the following Form must be filled up. A. CASES IN WHICH COMPENSATION WAS PAID FOR DEATH. (Compensation paid in respect of previous incapacity should be included in Table B). Cases where compensation (including medical or burial expenses, if any) was paid........................ ,................ . No. of cases in which Compensation was paid during 19 Total amount of Compensation paid during 19 B. CASES IN WHICH COMPENSATION WAS PAID FOR INCAPACITY. No. of cases in which Total amount of compensation was paid compensation paid during 19 during 19 Lump sum Periodical Payments. Payments. £ s. d. £ s. d. Cases continued from previous years. Cases in which the first payment of Icompensation was made during 19 ...... Total ... ... I P.N. 106 of 1955. Citation. Scale of fees and charges for medical aid to workmen. Cap. 219] Workmen's Compensation FEES AND CHARGES FOR MEDICAL AID. 1. These rules may be cited as the Workmen's Compensation (Fees and Charges for Medical Aid) Rules. 2. The fees and charges for medical aid to workmen within Sierra Leone shall be in accordance with the scale set out in the Schedule hereto.