_MAYEAIR CENTRE, th FLOOR, RALPH BUNCHE ROAD aveare Eee cee neice conn, Eraser he WORKMEN'S COMPENSATION - INJURY REPORT. Tobeco he Employer in ease injury too death oa workman 1) THEEMPLOER 2) Name 1) Ade on ms 9 » » » ° o ° 5 2 » 2 » » ° 9 » Indust oe Business = ‘THE WORKMAN INVOLVED IN EMPLOYMENT INIURY, Nae Adresome & Prmanc . se a . LD. a cccuption . ‘Workman's Job Description... a = en so ‘Wes beacon ox Poona, Acadenie Profesional qualification! Techni ade toc Ws the injured workman in your diet employment? YEN non Hk was be ‘working athe plac ofthe accidet unde tbe employment ofa contro thers? State Dele i ‘Monti or Daily earnings atthe time ofthe acideat.. © ‘asthe woeman fied suit YIN ...Has the workman previously fle suit pins you? CIN) oo yes, ive dtl of sits se = ‘THEACCIDENT ute & How: 7 Place: - ‘Cate ofthe Accident ‘Was the workman recorded on duty t your workplace on he injury dt What duty was he workman atsigned at he ime of nyinjury cased by Machinery 1. State mame of machine & prt casing the ary Watt fence or guarded ‘Wastin motion when the injury ocure Who was responsible fo switching it ono of? ‘Who switched on? His Ades s is PermanentHlome Address if diferent from above ‘State exactly whit the injured person was doing when beet injred 1 injury nt cause by machinery (eg Fea all, caring heavy objets) mame the ase an give abi description of how the wosdman ot inured ‘Was the ino peron under th influence of leahol any dik or drs at the tine tie accident. 4) THENWURY 5) Was if ful give the names ofall dependants of he deceased workman ifkaown, 2 1) Paculasof injury (a ceied by the HorpitallCompsny’s dost) S rete injures visible... State the probable prod of dsblement x 4) Nane the Hospta/DispensaryPsivato Clinic where hess ben treated following the secidet ©) Whether amited(¥0)...Daw when fst ete. 1) Date of dmisson Dae of Discharge 2) Attendance as outpatient prior to adi subsequent o hospitalisation, From t Wan thew doce medical Epa? (YIN) nif ye, plese provide copy 1») Amount expended on treatment aoe Who paid ori |) Was he injry seconded on an occurence bookfiniy etn (Pese atch copies) page?1) Was eran LD 104 form le YIN) fy, pleas rove copy. Haste retamed 1 wo? When '5) OBSERVANCE OF INSTRUCTIONS 43) Were there stunting intrucons! noice on bow to do the assigned work? Beiely explain . 1) War de workman guilty of ny miscondsct or dsobedens to sch isto or ater des le? : so, plese pve details ©) Whether the njred workman was provided with protective cletbinglouais eg loves, gum-os, telnet, goggles over ete (YIN) yes, state the date of sup... Did the workman sgn forthe sea nl 968, lease tach acopy ofthe signe eit ‘© Ws the workman found without he potective clothing guards tthe ime ofthe 146007 YOUN nnn RO BE FREON Wy i ©) Had his immediate seperisor brought othe atentio ofthe ised workman he secestity of wearing protective cothing/guads when hefner st he ater ‘eta! thee guards athe time of commencement ois work batbefore the occurenoeon the dat ofthe aside = 6) Ste the nares, adresses (permanent & Home) of he persons who witested the accident » a0 » 2 o = - ee