COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, 1993 by monkey6

VIEWS: 60 PAGES: 7

More Info
									W.C1.85

COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, 1993 SECTION 78 QUESTIONNAIRE

1.

What is the full trading name of the business in respect of which this application is made?

2.

The registration number allocated by the Workmen’s Compensation Commissioner to the business in respect of which this Questionnaire applies. (If different branches of your business are to be included please state the registration number of each branch)

3.

What is the estimated number of workmen in respect of which it is intended that the approval of the arrangement should apply?

YES NO 4. Do you operate your own private hospital?

5.

Are you in possession of a current valid Certificate of Registration issued by the appropriate authorities in terms of any regulation for the registration and control of private hospitals? (If the reply is in the affirmative a copy of the Certificate of registration should be attached for record purposes).

YES NO

6.

Is your hospital situated on the work premises? (If the reply is in the negative please state where it is situated and what the distance is between the hospital and the various properties it serves)

YES

NO

7.

How many beds are available in your hospital for your injured employees?

HCPWCL85(CEG)

1

8

(a) (b)

Are fracture beds available in your hospital? How many fracture beds are available for patients?

YES NO

(The name and make of such beds to be stated) 9. Is there a fully equipped operating theatre in your hospital? YES NO

10.

Is there a x-ray unit in your hospital? (If not, where is the nearest x-ray unit situated?) State the distance from the work premises

YES

NO

11.

How many nursing staff are employed in your hospital?

12.

(a)

Do you employ medical officers and if so, how many?

YES

NO

(b)

Is anyone of the medical officers (a) under contract with you? (b) being paid a salary? (c) If not employed by you how will the services be obtained and paid for?

YES

NO

13.

Has any of the medical officers any special qualifications or experience in operative and/or orthopaedic surgery? (a) What arrangements exist for obtaining the medical services in urgent cases?

YES NO

14.

(b)

How long does it take to respond to a call?

HCPWCL85(CEG)

2

15.

Is another medical practitioner easily available for the purpose of giving anaesthetics and/or assisting at difficult operations?

YES

NO

16.

Have you made arrangements with the following specialists in the different specialties to accept and treat your injured employees above the general practice level where necessary? (a) Surgical and Orthopaedic: Name and address of specialist

Is he under formal agreement with you to render services? (If not, how will his services be obtained?

YES

NO

(b)

Ophthalmological Name and address of Ophthalmologist

YES NO

Is he under formal agreement with you to render services? (If not, how will his services be obtained?)

YES

NO

(c)

Radiological Name and address of Radiologist

YES

NO

Is he under formal agreement with you to render services? (If not, how will his services be obtained?)

YES

NO

(d)

Pathological Name and address of Pathological

YES

NO

HCPWCL85(CEG)

3

Is he under formal agreement with you to render services? (If not, how will his services be obtained?)

YES

NO

(e)

Psychiatric Name and address of Psychiatrist

YES

NO

Is he under formal agreement with you to render services? (If not, how will his services be obtained?)

YES

NO

(f)

Dermatological (Scheduled Diseases) Name and address of Dermatologist

YES

NO

Is he under formal agreement with you to render services? (If not, how will his services be obtained?)

YES

NO

(g)

Oto-rhino-laryngological Name and address of specialist

YES

NO

Is he under formal agreement with you to render services? (If not, how will his services be obtained?)

YES

NO

(h)

Dental Name and address of dentist

YES

NO

Is he under formal agreement with you to render services? (If not, how will his services be obtained?)

YES

NO

HCPWCL85(CEG)

4

(i)

Physiotherapeutical Name and address of Physiotherapist

YES

NO

Is he under formal agreement with you to render services? (If not, how will his services be obtained?)

YES

NO

17.

If you no not operate your own private hospital, what is the name and address and distance of the hospital that will be providing the necessary hospital facilities for your injured employees?

18.

(a) (b)

Is the hospital under formal agreement with you to render facilities? If the reply is in the affirmative a copy of the written agreement entered into between your business and the hospital concerned must be attached for record purposes. If the reply is in the negative, how will the facilities be obtained?

YES

NO

(c)

(d) (e)

How many beds are reserved by the hospital for your employees? What amount, if any, is paid by you to the hospital for the reservation of these beds and for what period are the beds reserved? Amount R Period reserved

19.

What mode of conveyance is available to take injured employees to the hospital, xray unit and/or specialists consulting room’s etc?

N/A 20.

Further elucidation of any arrangement not mentioned above may be given separately

HCPWCL85(CEG)

5

21.

Do you undertake to comply with the requirements of the Workmen’s Compensation Commissioner in regard to the following: (a) to supply all injured workmen in respect of whom the approval will apply with full medical aid as provided for in the Act namely medical, surgical or hospital treatment, skilled nursing services, any special remedial treatment approved by the Commissioner and the supply and repair of any artificial part of the body or any device necessitated by disablement? YES NO

(b)

to ensure that medical aid is, at all times, given under the control of a medical practitioner who is registered with the SA Medical and Dental Council? YES NO

(c)

to supply artificial devices where these are required to the satisfaction of the Workmen’s Compensation Commissioner? (Where an artificial leg or arm is required two such limbs must be supplied in the first instance and must be kept in good working order for a period of at least two years from the date of the accident. The Commissioner may give further directions from time to time in regard to the supply of artificial devices) YES NO

(d)

to allow the doctor who treats your injured workmen to decide whether the facilities provided by you are sufficient to meet the circumstances of a case and/or where the services of a specialist or specialists are required in the opinion of your doctor, to remove such injured workmen without delay and free of charge to a hospital which is suitably equipped to give the necessary medical treatment and accommodation? YES NO

22.

Are you prepared to meet the above requirements satisfactorily and do you undertake to adhere to the conditions set out herein and to pay all medical aid expenses connected with the supply of medical aid to your injured workmen in terms of the Act if your arrangement for furnishing medical aid is approved in terms of section 81 subject thereto that(i) (ii) no medical aid expenses or part thereof shall be recovered from an injured workman; all disputes as to the necessity for or the character or sufficiency of any medical aid provided or to be provided in terms of chapter VIII of the Act, shall be determined by the Commissioner who reserves the right to withdraw an approval for an arrangement for the furnishing of medical aid by an employer in terms of section 78 at any time; YES NO

HCPWCL85(CEG)

6

I certify that, to the best of my knowledge and belief, the information furnished herein is correct. I do also hereby, on behalf of

(full trading name of business in respect of which application is made) undertake to comply with all the requirements set out herein and I do also undertake to advise the Workmen’s Compensation Commissioner immediately of any changes brought about in the arrangements to furnish medical aid, which might have an influence on the Commissioner’s approval of such arrangement.

Signed at _____________________ this _______________day of __________20_____

_______________________________________
SIGNATURE OF EMPLOYER OR HIS DULY AUTHORISED REPRESENTATIVE

HCPWCL85(CEG)

7


								
To top