2. Notice is hereby given that the Forms WCP-2 and WCP-3 set out in the Schedule to this Notice shall be used in compensation claims for the purposes of the Workers Compensation Act. 1 Workers Compensation (Compensation Forms) GN. NO. 779 (Contd.) ______ SCHEDULE ______ (Made under paragraph 2) ______ WORKERS COMPENSATION FUND MEDICAL SERVICES CLAIM FORM WCP-2 A. Patient information Names of Patient (Full Name) ............................................................ .................................... . Age ....................... Sex .................. ID No ....................................... Mobile No ................. .. Employer's Name............................................................................................... Treatment File No. ............................................................................................. B. Health facility (Hospital/Health Centre/Dispensary/Clinic) Name of health facility………………………………………………………….. . . Address of facility..............................Region .............................District............................. C. Medical information Nature of illness/injury (Mark (V) appropriately) Occupational Accident Occupational Disease Diagnosis…………………………… date of diagnosis... ... .............................. Is the condition recurrent or chronic ………………………………………………………………… Are the any underlying conditions whish could result in this illness or Injury (yes or no, if yes specify) ……………………………………………………………………………………………………….. D. Break down of expenses Consultation Fee .................................................................................... .................. Admission Cost ................................ No of days ........................................................... . INVESTGA TION INVESTGA TION INVESTGA TION INVESTGA TION INVESTGA TION 2 Workers Compensation (Compensation Forms) GN. NO. 779 (Contd.) TOTAL PROCEDURES PROCEDURES PROCEDURES PROCEDURES TOTAL GRAND TOTAL: ...........................................................· ................... .. E. Certificate by medical practitioner I certify that the above information is true, to the best of my knowledge and the medical expenses incurred were as a result of the illness/injury referred to. Prescriber's names (full name) ................................ ... .............. Designation .............................................................. . Qualification ............................................... Signature .. .................................... Date .............. .. Official stamp ............................................................ ... .. F. Patient Certification: I certify to get the above mentioned Investigation(s) is/were performed as confirmed by my signature hereunder Signature………………………………….. Date………………………… 3 Workers Compensation (Compensation Forms) GN. NO. 779 (Contd.) WCP-3 WORKERS COMPENSATION FUND MEDICAL PROGRESS REPORT FORM (This form shall be filled by a Medical Practitioner) A. Employee/Patient identification Medical File No. Name of the p atient Sex Date of Birth B. Name and address of health care provider ……………………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………………. C. Type of medical progress (Mark(../) appropriately) Hospitalized Scheduled visit Others (specify) D. Medical care services details Date of Diagnos is ca re (DD/MM/ Y Y ) Condition of the patient (major clinical findings from history, physical examination and tests) Summary description of health care services rendered (type of consultation, medications, medical tests, procedures etc.) Date of vi next sit (DD/MM/ Y Y ) Additiona Duty l Exemptio n Days Given (i.e., ED and/orLD) Medical Practitioner's Remarks ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… 4 Workers Compensation (Compensation Forms) GN. NO. 779 (Contd.) DECLARATION I declare that what I have stated herein above 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 Dar es Salaam, JOHN K. MDUMA, 25th October, 2021 Director general 5
