Copyright Act, 1978
R 385
Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)Consultation fees in accordance with the Consultation Services UnitAnnexuresAnnexure AMRI Motivation Form for Employee’s Injured on Duty |
The Department of Labour: Compensation Fund
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Claim Number: |
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Employee's Name: |
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Employees ID No: |
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Name of Employer: |
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Date of Accident /Injury: |
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Type of injury: |
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Brief description of how injury occurred: |
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Previous clinic / imaging investigations done, and dates: |
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Imaging investigation required: |
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Motivation / Clinical indications for the investigation: |
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Requesting Doctors Name: |
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Practice Number: |
Date of Referral |
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This form should preferably be typed
