*FINAL / PROGRESS MEDICAL REPORT IN RESPECT OF AN ACCIDENT

FINAL / PROGRESS MEDICAL REPORT IN RESPECT OF AN ACCIDENT (WCL5)
Please ensure that this form is completed by no later than 48 hours after receipt thereof.
The Compensation of Occupational Injuries and Diseases Act, 30 of 1993, requires Medical Practitioners to complete form/s within specified time periods and unfortunately failure to complete and submit the designated forms within the required time periods, may lead to further legal action being taken against the Medical Practitioner by the relevant governmental institution.
Claim Number
Employee Details
Names and Surname of employee

First NameLast Name
Employee I.D Number
Employee Address

Address Line 1

Address Line 2

CityState

Zip Code
Province
City
Postal Code
Employer details
Name of Employer
Employer Address

Street Address

CityState / Province

Postal / Zip Code
City
Province
Postal Code
Date of Accident

DayMonthYear
Date
Case Details
1. Describe any operation(s)/procedure(s)/test(s) carried out and date(s)
2. Prognosis and further treatment?
3. (a) From what date has the employee been fit for his/her normal work?

MonthDayYear
Date
Date

MonthDayYear
Date
4. If so, describe in detail any present permanent anatomical defect and/or impairment of function as a result of the accident: (Loss of movement, if any, must be indicated in degrees at each specific joint).
Medical Practitioner Details
Name of Medical Practitioner
Date of signature

DayMonthYear
Date
Address
Practice number
I certify that have by examination, satisfied myself that the injury(ies) of the employee is the result of the accident.

Signature of Medical Practitioner/Chiropractor
Signature

Clear
Should be Empty:

FINAL / PROGRESS MEDICAL REPORT IN RESPECT OF AN ACCIDENT (WCL5)

Please ensure that this form is completed by no later than 48 hours after receipt thereof.

Employee Details

Employer details

Case Details

Medical Practitioner Details