Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)

Claim Number:

Employee's Name:

Employees ID No:

Name of Employer:

Date of Accident /Injury:

Type of injury:

Brief description of how injury occurred:

Previous clinic / imaging investigations done, and dates:

Imaging investigation required:

Motivation / Clinical indications for the investigation:

Requesting Doctors Name:

Practice Number:

Date of Referral