Mine Health and Safety Act, 1996 (Act No. 29 of 1996)

Regulations

Purchase

Annexure C

USER GUIDELINE ON HEALTH INCIDENT REPORT (HIR)

A. DETAILS OF EMPLOYER

•	Name of mine: The name of the mine must be filled in.

•	SAMRASS Code: The Mine's SAMRASS code must be filled in.

•	Mine Code: The Mine's SAMRASS code must be filled in.

•	Mine Address: The Mine's postal address must be filled in.

B. PERSONAL DETAILS OF THE AFFECTED EMPLOYEE

Supply ALL available information on personal details.

U/G and surface Indicate the employee's designated working area

C. DETAILS OF DISEASE

•	Date diagnosed: The date when the employee was diagnosed, e.g. DD/MM/YYY.

•	Disease: Indicate with an "X" which disease/s the employee has been diagnosed with.

D. DETAILS OF SUBMISSION FOR COMPENSATION

•	Submitted for compensation: Mark with "X" if a compensation claim has been submitted.

•	Date Submitted: Date on which the compensation claim was submitted.

•	Disease Caused Death: State whether the employee died as a result of the disease.

•	Employment Status Changed: State if the employee's occupation has changed as a result of the disease.

•	Date: Indicate the date from which the employee's employment status has changed.

•	Compensation Houses/ Bodies Indicate which institution handled the compensation claim eg.:

Rand Mutual Assurance, Compensation Commissioner or

Medical Bureau for Occupational Diseases

•	Compensation / claim number Indicate the compensation/ claim number

E. WORK AND / EXPOSURES THAT LED TO THE DISEASE

Supply ALL available information on the affected employee's work and work exposures.

F. EMPLOYMENT HISTORY RECORD:

Supply ALL information

G. GENERAL DETAILS:

Supply ALL information and sign the form where indicated

[Annexure C of form DMR 231 inserted by Notice No. R. 702 dated 12 September 2014]