【法规名称】
【法规编号】 79975 什么是编号？
【正 文】
第3页 CAP 282A EMPLOYEES' COMPENSATION REGULATIONS
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[接上页] (a) Basic salary/wages (b) Food allowances/value of free food provided by employer (c) Other items: ____________________________________ (please specify) Total (a) + (b) + (c) $ ______________/month $ ______________/month $ ______________/month $ ______________/month Average monthly earnings of the employee for the past 12 months (or total period of employment, if less than 12 months) preceding the accident were $ ______________/month G. Fatal accident (to be completed where accident results in death) Whether police was notified □ Yes _____________________ (name of police station) Name and address of next-of-kin of the deceased employee Relationship with the deceased employee □ No Telephone No. H. Direct settlement (to be completed only where the injury results in temporary incapacity for not more than 7 days and no permanent incapacity, and the employer and employee have chosen to directly settle the employees' compensation claim) Period of sick leave from ______/______/____ to______/______/____ Day/Month/Year Day/Month/Year _____/_____/____ to_____/_____/____ Day/Month/Year Day/Month/Year Total number of sick leave days: ____________ days Amount of compensation: $ __________________ □ paid □ to be paid on ______/______/_____ Day/Month/Year I. Place of accident (tick one box) The accident occurred in-(Note 7) Construction site □ 01 Building worksite □ 02 Civil worksite □ 03 Renovation/repair of existing buildings Shipyard □ 04 Floating vessel □ 05 Non-floating vessel □ 06 Maintenance workshop Manufactory □ 07 Production area □ 08 Maintenance workshop □ 09 Loading/unloading area □ 10 Storage area Others □ 11 Container yard □ 12 Catering establishment □ 13 Please specify ________________ Activity carried out on the site at the time of accident (Note 8) J. Nature of injury (Note 9) Describe the nature of injury Indicate nature of injury (tick one box)- □ 01 Abrasion □ 02 Amputation □ 03 Asphyxia □ 04 Burn (heat) □ 05 Burn □ 06 Contusion & bruise □ 07 Concussion □ 08 Laceration and cut □ 09 Dislocation □ 10 Crushing □ 11 Electric shock □ 12 Fracture □ 13 Puncture wound □ 14 Sprain & strain □ 15 Freezing □ 16 Poisoning □ 17 Irritation □ 18 Nausea □ 19 Multiple injuries □ 20 Others (please specify) _________________ Part of body injured (tick one box)- Head □ 21 Skull/scalp □ 22 Eye □ 23 Ear □ 24 Mouth/tooth □ 25 Nose □ 26 Face Neck & Trunk □ 31 Neck □ 32 Back □ 33 Chest □ 34 Abdomen □ 35 Trunk □ 36 Pelvis/groin Upper Limbs □ 41 Finger □ 42 Hand/palm □ 43 Forearm □ 44 Elbow □ 45 Upper arm □ 46 Shoulder Lower Limbs □ 51 Hip □ 52 Thigh □ 53 Knee □ 54 Leg □ 55 Ankle □ 56 Foot □ 61 Multiple locations (please specify) _____________ K. Type of accident (tick one box) (Note 9) □ 01 Trapped in or between objects □ 02 Injured whilst lifting or carrying □ 03 Slip, trip or fall on same level □ 04 Fall of person from height* ___ metres * distance through which fell □ 05 Striking against fixed or stationary object □ 06 Striking against moving object □ 07 Stepping on object □ 08 Exposure to or contact with harmful substance □ 09 Contact with electricity or electric discharge □ 10 Trapped by collapsing or overturning object □ 11 Struck by moving or falling object □ 12 Struck by moving vehicle □ 13 Contact with moving machinery or object being machined □ 14 Drowning □ 15 Exposure to fire □ 16 Exposure to explosion □ 17 Others (please specify) _______________ L. Agents involved, if any (tick one or more boxes) (Note 9) □ 01 Equipment for lifting/conveying □ 02 Portable power or hand tools □ 03 Other machinery, please specify: Type: ___________. Part causing injury: □ (a) prime mover □ (b) transmission part □ (c) working part □ 04 Material/product being handled or stored □ 05 Ladder or working at height □ 06 Sewage, manhole or other confined space □ 07 Movable container or package of any kind □ 08 Floor, ground, stairs or any working surface □ 09 Gas, vapour, dust or fume □ 10 Electricity supply, wiring apparatus or equipment □ 11 Vehicle or associated equipment or machinery □ 12 Others (please specify)_______________ Describe briefly the agents you have indicated (Note 9) M. Sketch (to supplement the descriptions given above, if considered necessary) For official use only I.A./Non-I.A. Investigation Processed by End of Part I -Part II- (To be completed if the accident occurred on a construction site) N. Type of work performed by the employee at the time of accident (tick one box) □ 01 Concreting □ 02 Woodworking □ 03 Glazier work □ 04 Reinforcement bar bending □ 05 Bamboo scaffolding □ 06 Tubular scaffolding □ 07 Painting □ 08 Plastering □ 09 Arc/gas welding |
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