W.Cl.
26
labour
Department:
Labour
REPUBLIC OF SOUTH AFRICA
Claim Number: .......................................
PROGRESS/FINAL MEDICAL REPORT IN RESPECT OF AN OCCUPATIONAL DISEASE
(*Delete which is not applicable)
COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, 1993
[Section 74(2) – Commissioner's rules, forms and particulars – Annexure 20]
Surname of Employee ......................................................................................................................................................................
(Block letters)
Full Names .......................................................................................................................................................................................
ID Number .......................................................................................................................................................................................
Address ............................................................................................................................................................................................
Name of employer ............................................................................................................................................................................
Date of diagnosis ..............................................................................................................................................................................
1. From what date has the employee been fit for his/her work?
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or
Since what date has the employee been fit for work in the open labour market? ..........................................................................
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2. (a) Was the employee required to change his/her occupation following medical advice? ...........................................................
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(b) If so, please give the reason ...................................................................................................................................................
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3. (a) Has there been any permanent loss of function which resulted from the occupational disease? ..........................................
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(b) If so, give a detailed description thereof of substantiated by special examinations where necessary ...................................
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4. Has the employee's condition become stabilised? ........................................................................................................................
If so, describe in detail any permanent anatomical defect and/or impairment of functions of the occupational disease ...............
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Account in respect of consultation and/or procedure(s)
Your Account No. ............................................................ PR No. ......................................................
Description of Place and dates of Item of Tariff R c
service treatment or visits
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) ........................................................................... .....................................................................................
Signature of medical practitioner/chiropractor
Name printed: .........................................................................
Registered address: .........................................................................
: .........................................................................
: .........................................................................
N.B.: Progress reports must be submitted on a monthly basis to the Compensation Commissioner or mutual association or employer individually
liability as the case may be until the employee's condition has become stabilised when a final medical report should be submitted.
Call Centre No.: 086 010 5350 - Fax No.: (012) 323-8627 or (012) 323-6986
E-mail: cf-info@labour.gov.za - Website: www.labour.gov.za
