2. Supervisor’s name……….……Cellphone…….……Section/Department……. Initial treatment date ……………... Name of treating Hospital………………………. E. PARTICULARS OF OCCUPATIONAL DISEASE Date of diagnosis…………….... Occupational disease diagnosed …………….………… Date of reporting disease to employer…………………………………………………. Section/Department where exposure occurred on employer’s premises…………….…... Briefly describe the sequence of activities associated with the disease diagnosed….…………………………………... ……………………………………………………………………………………………… ……………………………………………………………………………………………… Name of the Hospital where the diagnosis was established……….……………….……… Name medical practitioner who diagnosed the disease………………………….….……... ………………………………………………...........Cellphone No. …………….……… (Attach diagnosis reports) F. PARTICULARS OF DEATH (mark (√) appropriately) Name of employee’s representative……...………………………………… Cellphone No. …………………………………………………….………. The physical address of the employee’s representative ………………...………………………………………… Date of death………………………………………………………………. Cause of death - occupational accident ( ) or occupational disease ( ) Date of reporting to the employer ………………………..………………………….. Place where Death occurred (street, ward, city) ………............................................................................. Did the incident occur on the employer’s premises? (Yes/No) …….... Section/Department …………………………………………………………..…….. Specific activity the deceased employee was performing when event/exposure occurred ...…………………………………………………………………. Briefly describe the sequence of events /exposure and specify object/exposure which directly produced the accident/ disease that led to his /her death………………….......... …………………………………………………………………………………………… Name of the hospital where death was confirmed.……………………. ……………….. Name of Medical practitioner who confirmed death ……..…Cellphone No……………… PART: G EMPLOYEE’S DECLARATION I, ………………………………………………………………., declare that what I have stated hereinabove is true to the best of my knowledge and if it is proved that there is 7 GN. NO. 668 (Contd.) Workers Compensation (Amendment) forgery or fraud in relation to the information provided, legal action should be taken against me. Signature…………………………………………………………………………………. Date………………………………………………………………………………………… EMPLOYER’S ACKNOWLEDGEMENT OF RECEIPT OF NOTIFICATION Date of receipt of the notification by the employer Notified by (Name and designation) Received by (Name, designation, signature and official stamp) I, ………………………………………………………………, information provided hereinabove is true to the best of my knowledge. declare that the 8 GN. NO. 668 (Contd.) Workers Compensation (Amendment) Employee’s WCF No…………………… WCC-2A INITIAL MEDICAL REPORT ___________ (Made under regulation 21(1)) ___________ (This form shall be filled by a medical practitioner in triplicate) A. EMPLOYEE’S PARTICULARS First Name…………………. Middle Name ……………. Last Name ………….……. Date of birth…………. Medical File no……………. Job Title…….………………. Employer’s Name.………………………………. Employee’s ID No……………. B. PARTICULARS OF HEALTH CARE PROVIDER Name of health care provider ………………………………………………………... Contact address …………………………… Region/District …….……….……………... C. PARTICULARS OF OCCUPATIONAL ACCIDENT OR DISEASE i. ii. iii. iv. Date of accident or diagnosis of occupational disease…………… (DD/MM/YY) Date of the first consultation at this facility…….…………...…(DD/MM/YY) Description of injuries/condition of the employee at the time of examination ……………………………………………………………………………………… ……………………………………………………………………………………… …………………………………… Diagnosis…………………………………………………………………………… ………………… D. MEDICAL PRACTITIONER’S ASSESSMENT i. ii. iii. Does the employee require hospitalization? (Yes/No). Circle appropriately If Yes, which unit? ………………………….… Does the employee require a follow-up visit? (Yes/No). Circle appropriately If Yes, when is the next visit? ……./……/…….. (DD/MM/YY) Is the employee able to resume his duties? (Yes/No). Circle appropriately If No, exempted duty days……….…; From:…….…. To: …….………. Reason: ……………………………………………………………………………………… light duty days………...; From: ………………. To: ……… Reason: ……………………………... iv. Medical Practitioner’s remarks (if applicable, attach a medical report) ……………………………………………………………………………………… ……………………………………………………………………………………… ………………………… 9 GN. NO. 668 (Contd.) Workers Compensation (Amendment) DECLARATION I declare that what I have stated hereinabove is true to the best of my knowledge. Name of medical practitioner……………….……. Designation ……………………… Registration No……………... Cell phone……………… E-mail…………………….……... Signature………..................... Date…………………............................. (DD/MM/YY) Official stamp 10 GN. NO. 668 (Contd.) Workers Compensation (Amendment) Employee’s WCF No……………………. WCC-2B MEDICAL PRACTITIONER’S REPORT ___________ (Made under regulation 21(2)) ___________ (This form shall be filled by a medical practitioner in triplicate) A. EMPLOYEE’S PARTICULARS First Name………………. Middle Name ………………. Last Name ……………………. Medical File no…………………… Employer’s Name. ………………………………… B. PARTICULARS OF HEALTH CARE PROVIDER Name of health care provider ….……………………………………………………... Contact address …………….…………… Region/District …….……………………... C. DETAILS OF SERVICES RENDERED i. Hospitalisation (fill appropriately) Date of Discharge Date of (DD/MM/YY) Admission (DD/MM/YY) Reason ii. Medical investigations, procedures and surgeries done a) Investigations………………………………………………………………….… b) Procedures………………………………………………………………………. c) Surgeries Date of surgery (DD/MM/YY) Type Indication (s ) Anaesthesia Surgeon’s name and qualification D. CURRENT STATE OF EMPLOYEE (PATIENT) (MARK (√) IN THE APPROPRIATE Employee status BOX) i. Fully recovered (Resumed duties without permanent loss of body part/function) Recovered with permanent loss of body part/function (Go to the table (ii) below) Need medical follow up (Outcome not yet fully decided) Death (Cause of death) ii. For permanent loss of body part (s) or function (s) (complete table below) Body part or function(s) impacted/affected Manner of loss Degree of Functions impaired or Level of loss of body part Rehabilitation recommended 11 GN. NO. 668 (Contd.) Workers Compensation (Amendment) iii. Date when declared fit returning to work with /without restrictions……/……/…... (DD/MM/YY) E. FINAL DIAGNOSIS i. What is the final diagnosis? ……………………………………………………….………………... Do you think this condition is occupational? (Yes/No). Circle appropriately. ii. Why? ………………………………………………………………………..……………………… iii. Medical practitioner’s opinions and recommendations (in case of referral please advise here) ………………………………………………………………………………………………………… ………………………………………………………………………………………………………… DECLARATION I declare that what I have stated hereinabove is true to the best of my knowledge. Name of medical practitioner…………………………. Designation ……………………… Registration No……………... Cell phone……….….…… E-mail……………………... Signature………..................... Date…………………............................... (DD/MM/YY) Official Stamp JENISTA J. MHAGAMA Dodoma, 20th August, 2021 Minister of State, Prime Minister’s Office, Policy, Parliamentary Affairs, Labour, Youth, Employment and Persons with Disability 12
