5 ɾ ïÀåó ¡å¨îºø ÀºòÆ

General 5
*
(A4 S. & E.) 1/59
(Internet Version)

1357, 1381, 1386 ƾ Äê¼Èà ïǪëÈåÌè Æ´ïºà ͼúÌè ¡¾ºëÇæ ¾øÉå¶ê ¢ÈàõŠ ¨ø×Ä
APPLICATION FOR ACCIDENT LEAVE UNDER F.R.R. 1357, 1381, 1386

¡â¨Æ ¼ú¾Æ
....................................................................... .......................................................................
No. Date

§ï‰ ¡â¨Æ
.......................................................................
Your No.

From : ............................................................................................................................................................................................................ 諭à

To : ........................................................................................................................................................................................................... ïɺ´ Æ.

1. (¡) ïÌàɨÆåïªà ¾Ä ÌÍ º¾ºëÇ

(a) Name and designation of employee

(¡å) ÀºàÉì ¼ú¾Æ

(b) Date of appointment

(¡æ) Éæ´êÀà ÀòÄå¸Æ (ïï¼¾ø¨ Éæ´êÀà Àè´¼/ ÄåÌè¨ Éæ´êÀà Àè´¼ ƾ ÂÉ)
(c) Rate of pay (daily or monthly basis)

(¡ç) §Íê´/ ¡æÆ´ ¢Çæ¼ú¾ÉÈºà ¡å¸à¶êïŒ ¾èÉå¶ê ¼ú¾ÉȺà Éæ¶ ¨Ç¾à¾´

ºø?
(d) Is he/she expected to work on Sundays and Public Holidays

2. ͼúÌè ¡¾ºëÇ Ìèó Éì ¼ú¾Æ

Date of accident

3. ͼúÌè ¡¾ºëÇ ÌèóÑÄ´ ïÍàºëÉ ?

Cause of accident

4. ͼúÌè ¡¾ºëÇ Ìèó Éì Ìà»å¾Æ

Place where accident occurred

5. ͼúÌè ¡¾ºëÇ Ìèóɾ ¡ÉÌà»åû ¨Š¨ÇæÉå ïÌàÉïÆà ïƼû Ìè ¡å¨åÇÆ

Manner in which the workman was employed at the time of accident

6. *Àרà˸ƨà Àɺàɾê ÈæŸ ¼, ¦ïÌà ¾Š _

*Was and enquiry held? If so, are you satisfied that –
(¡) ïÌàɨÆå ͼúÌè ¡¾ºëÇ´ ÄêÍê¸ ÀçïŒ Çå°¨åÖïÆà ïƼû ÌèÆ¼û Âɺà,
(a) the employee met with the accident while on duty ; and

(¡å) ͼúÌè ¡¾ºëÇ ÌèóÑÄ´ §Íê ɪ ¨øÉÆêºë ï¾åɾ Âɺà, §Â´ ¦àºàºë
ïªåÌà ºø?
(b) He was himself not responsible for the occurrence of the accident

7. ¨Š¨Çæ ɾà¼ú ¡å³å À¾ïºà 57 (i) Éæ¾ø ɪ¾àºøïÆà Àò¨åÇ “Q” ¼Ç¾
¡å¨îºø ÀºòïÆà ÈèÆì ÉåÚºåÉ¨à ¨Š¨Çæ ɾà¼ú ï¨åÄÌåÖÌà´ ÆÉå ºø?
Has a report on form “Q” been made to the Commissioner of Workmen’s
Compensation in terms of section 57 (i) of the W.C.O.?

(ͼúÌè ¡¾ºëÇ ÌèóÉì ¼ú¾ïÆà Ìè´ ¢¼úÖÆ´ Àè´ Àè´ ¼ú¾ 7 ¨´ Éæ‘ïƾà
ïÌàɨÆå ï¾åÀ數 ÌèïÆà ¾æºà¾Š “Q” ¼Ç¾ ¡å¨îºø ÀºòïÆà ÈèÆì
ÉåÚºåÉ¨à ¨Š¨Çæɾà¼ú ï¨åÄÌåÖÌà ïɺ Ææ—Æ Æêºë ï¾åïŒ.)
(Report on Form “Q” need not be sent to C.W.C. if the employee has not absented
himself for more than 7 consecutive days immediately succeeding the date of accident.)

8. ïïɼñ Ìͺø¨ïÆ¾à ¾øÚï¼àÊ ¨Ç ¡æºø ¾øÉå¶êÉ (ïïɼñ ĸà¶ÈïÆà ÉåÚºåÉ

¡Äê¸å ¡æº.)
Period of leave recommended by the Medical certificate (Medical board
report attached)

9. ïïɼñ ¾øȽåÖÆå —Ìè¾à ¾èÚï¼àÊ ¨Ç¾ ȼ ¾øÉå¶êïŒ Äê¼Èà ¡ªÆ

The monetary value of the leaver recommended by the Medical Officer

* ͼúÌè ¡¾ºëÇ ÌèóÑ ÌºøÆ¨à ¡æºëκ ÀÖ¨àË¸Æ ÀæÉæºà—Æ ÆêºëÆ. ÀרàËå ¨Ç¾ ¾øȽåÖÆåïªà ¡¼ÍÌ༠Àò¨åÊïÆà Àè´ÀïºàÄ Ì¿Í¾à ¨Î ÆêºëÆ. Àרà˸ïÆà
Ì´Í¾à ¼ ¦Æ´ ¡æ•¸èÆ ÆêºëÆ.
* Inquiry to be held within one week of the accident. The comments of the Inquiring Officer to be given on the copy of the statement itself. Notes of inquiry to be attached.
10. ïïɼñ ¾øȽåÖÆå/ ĸà¶ÈÆ Ìͺø¨ ¨Ç ºø?
Has the Medical Officer/ Board certified that –

(¡) ïÌàɨÆå Çå°¨åÖÆ´ ÌêóÌê Âɺà,

(a) the employee is fit for duty;

(¡å) ¾øÚï¼àÊ ¨Ç¾ ȼ ¾èÉå¶ê ¨åÈïÆà §Íê ïÆåàªñ Àòºè¨åÇ ïª¾

¡æºø Âɺà,
(b) has taken suitable treatment for the period of leave recommended,
(¡æ) ɾà¼ú Ì¿Íå Ɗ ¢ÈàÈéÄ¨à ¢¼úÖÀºà ïɺæ Æú ï¾åÌèºøÆ Íæ¨ø
Âɺà,
(c) no claims for Compensation are likely to arise;

ïïɼñ ¾øȽåÖÆå/ ĸà¶ÈÆ Ìͺø¨ ¨Ç ºø?

(ïÄÄ ¾øÆÄƾഠ¡¾ê¨íÈ ï¾åɾ ïïɼñ Ìͺø¨ ¾øÉå¶ê ¢ÈàõŠ
ÀºòÆ´ ¡æ•¸éÄ´ ïÀÇ ¦Ä Ìͺø¨ ïÄÄ ¾øÆÄƾഠ¡¾ê¨íÈÉ
ÀèÎïè ÆÈ ¨Ç¾ê Ì¿Íå ïïɼñ ¾øȽå×¾à ïɺ ¡åÀÌê Ææ—Æ Æêºë Æ.)
M.C.C. not complying with these requirements should be returned to the
M.O.O. for compliance before attaching them to the leave application)

11. ïÌàɨÆå ¡åÀÌê É涴 ¡å ¼ú¾Æ

Date the employee returned to work

12. ¼æ¾´Ä ¡¾êĺ ¨Ç ¡æºø ¾øÉå¶êïŒ ¨åÈ ÀփïØ¼Æ ÌÍ ¦Æ

¡¾êĺ ¨Ç ¡æºàïºà ¨ÉÇ¨ë —Ìè¾à ¼ ƾ ÂÉ
Period of leave already sanctioned and by whom?

13. ¼æ¾à ¢ÈàȾ ¾øÉå¶ê

Period of leave now applied for

14. ïɾºà ¨øÉÆêºë ¨Çæ¸ê ¡æïºåºà, ¦àÉå -

Other remarks, if any -

..................................................................................
ÉåÚºå ¨Ç¾ ¾øȽåÖÆåïªà ¡ºà̾ ÌÍ º¾ºëÇ.
Signature and Designation of Reporting Officer.

¡â¨Æ
To : ...................................................................................................................................... .......................................................................
No.

................................................................................................................. ïɺ´ Æ.
¼ú¾Æ
.......................................................................
Date

.................................................................
ï¼Àåںàºë Àò½å¾èÆå.
Head of Department.

¡â¨Æ
.......................................................................
To : ...................................................................................................................................... No.

................................................................................................................. ïɺ´ Æ.
¼ú¾Æ
.......................................................................
Date

.................................................................
Ìà»üÇ ïÈਊ.
Permanent Secretary.

H - 022255 (2004/10) Êòé Èâ¨å Ç°ïÆà Äê÷¸ ï¼ÀåںàºëÉ