Mine Health and Safety Act, 1996 (Act No. 29 of 1996)NoticesGuidance Note on Medico-Legal Investigations of Mine DeathsAnnexuresAnnexure 4 : Referral letter - Mine related deaths |
RERERRAL LETTER -MINE RELATED DEATHS
SECTION A: Details of investigator
Name of the investigator:_______________________________
Contact details: telephone number: ______________________
e-mail address_________________________________________
Name of mine:_________________________________________
Physical address:_______________________________________
Date of incident: year_______/ month__________/ day______
Estimated time/date of death: hour____: minutes_____/year ______/month_______/day___
Date and time of collection of body by: year______/month______/day______ hour_____:minutes____
SECTION B : Deceased particulars
Sex: Male o Female o
Age: __________ID/Passport no: ________________________
Rigor Mortis: o Hypostasis/Liver: o Body Temperature: ________oC
Type of work employed in: _____________________________________________________
SECTION C : Conditions at site of incident
Underground o Surface o
Suspected cause of injury/death:
| 1. | Electrical discharge / Electrocution |
Circumstances: _________________________________________________________________
| 2. | Entrapment |
Circumstances: _________________________________________________________________
| 3. | Explosions: |
Circumstances: __________________________________________________________________
| 4. | Fall |
Circumstances: __________________________________________________________________
Height _____________ Moving vehicle ____________________ Other
| 5. | Burns |
Circumstances: ___________________________________________________________________
Flame: o Liquid: o Chemical: o Gas:o Other o _______________________________
| 6. | Thermal Stress |
Ambient temperature: ____________________ oC
Circumstances: ___________________________________________________________________
7. Transport: Tram/Lifts/Vechile/Other
Single accident o Frontal impact: o Operator o
Multiple accidents: o Side impact: o Passenger o
Roll over: o Rear impact: o Pedestrian o
Circumstances: __________________________________________________________________
| 8. | Gassing/poisoning |
Suspended gas/es: _______________________________________________________________
Circumstances: __________________________________________________________________
| 9. | Sudden Death/Suicide/Unknown |
Circumstances: __________________________________________________________________
SECTION D: Signatures
Rank of the investigating officer: _______________________________________________________
Signature of investigator: _____________________________________________________________
Date: year _________/month ____________ /day_________
Time: hour________: minutes_____________