Mine Health and Safety Act, 1996 (Act No. 29 of 1996)

Regulations

Chapter 21 : Forms

Annexure

Annexure C
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Annexure C

 

USER GUIDELINE ON HEALTH INCIDENT REPORT (HIR)

 

A.        DETAILS OF EMPLOYER

•        Name of mine:                                The name of the mine must be filled in.
•        SAMRASS Code:                        The Mine's SAMRASS code must be filled in.
•        Mine Code:                                The Mine's SAMRASS code must be filled in.
•        Mine Address:                                The Mine's postal address must be filled in.

 

B.        PERSONAL DETAILS OF THE AFFECTED EMPLOYEE

Supply ALL available information on personal details.

U/G and surface                        Indicate the employee's designated working area

 

C.        DETAILS OF DISEASE

•        Date diagnosed:                        The date when the employee was diagnosed, e.g. DD/MM/YYY.
•        Disease:                                Indicate with an "X" which disease/s the employee has been diagnosed with.

 

D.        DETAILS OF SUBMISSION FOR COMPENSATION

•        Submitted for compensation:                Mark with "X" if a compensation claim has been submitted.
•        Date Submitted:                        Date on which the compensation claim was submitted.
•        Disease Caused Death:                        State whether the employee died as a result of the disease.
•        Employment Status Changed:                State if the employee's occupation has changed as a result of the disease.
•        Date:                                        Indicate the date from which the employee's employment status has changed.
•        Compensation Houses/  Bodies                Indicate which institution handled the compensation claim eg.:

Rand Mutual Assurance, Compensation Commissioner or

Medical Bureau for Occupational Diseases

•        Compensation / claim number                Indicate the compensation/ claim number

 

E.        WORK AND / EXPOSURES THAT LED TO THE DISEASE

Supply ALL available information on the affected employee's work and work exposures.

 

F.        EMPLOYMENT HISTORY RECORD:

Supply ALL information

 

G.        GENERAL DETAILS:

Supply ALL information and sign the form where indicated

 

[Annexure C of form DMR 231 inserted by Notice No. R. 702 dated 12 September 2014]