Mine Health and Safety Act, 1996 (Act No. 29 of 1996)RegulationsChapter 21 : FormsAnnexureAnnexure B |
Annexure B
Employee Consent Form
I ___________________________________________________________________________________ (full names and surname) understand that my personal information regarding disease and employment will be sent as regulated to the Health Incident report database and may be used for purposes of reporting of occupational disease in mines and research.
I have been informed that confidentiality will be maintained in terms of Section 15 of the Mine Health and Safety Act, 1996, as amended.
________________________________________ _______________________________________________________
Employee Occupational Medical Practitioner
(Signature) (Signature)
Date: ___________/ ____________/ ________________ Date: ____________/____________/_________________
____________________________________________ _____________________________________________
Witness 1 Witness 2
(Signature) (Signature)
Date: __________/____________/__________________ Date: ____________/___________/___________________
[Annexure B of form DMR 231 inserted by Notice No. R. 702 dated 12 September 2014