Injury Benefit Application Form

Injury Benefit Application Form

Fields marked with an asterisk '*' are mandatory In case of difficulties call 159 or 25903000

Section 2: Permanent Address

Locality * Street * Postal Code

Section 1: Personal Details

Title * Surname * Name *

Date of Birth * [dd/mm/yyyy]

Scope for this form:

Case of INJURY

Case of DISEASE / MEDICAL CONDITION RELATED TO WORK

Tick as applicable (you can select more than one option as necessary)

Claim for Injury Benefit to the Department of Social Security Report to the Occupational Health and Safety Authority

Fields marked with an asterisk '*' are mandatory In case of difficulties call 159 or 25903000

Section 3: Applicant Details

Status: _{single person}

married / civil union single parent

separated maintaining spouse separated not maintaining spouse Gende Nationality

Select this box if you wish to receive SMS notifications about benefit payments.

Telephone number Mobile number

Fax number E-Mail

Work: _Employed Part-Time

Self Employed Full-Time

Type of work

I work with a roster / shift or six days per week Yes No

I don't work on and _{Yes No}

Spouse Details (if applicable):

ID Number Name Surname

Spouse works full time? Yes No

Payment Details

The payment should be deposited in a bank Savings or Current account but not a Loan account. Only in the case of a Bank Garnishee Order you can receive payment by cheque. Yes No Bank

IBAN

The IBAN number that you provide will be used for all benefit payments, both current and future.

Fields marked with an asterisk '*' are mandatory In case of difficulties call 159 or 25903000

Section 4: Case Details

Information about the Case

Injury Case: Date of Injury Time of Injury

Disease/Medical Case: The condition is the result of an Injury at Work Yes No

i. Information about the work place/

environment that caused the case

(example: factory, warehouse, dockyard, construction site, hotel, restaurant, hospital, etc)

ii. What caused the case

(example: slip, fall from a height, dropping of heavy objects or liquids, burns, breakage of material, loss of control or break-down of machinery or tools, gas leakage, impact by an object, exposure to chemicals, etc)

iii. Provide more details about machinery,

tools, substances, vehicles, scaffolding or other items you were working with before the accident.

iv. With what was the impact causing the

accident?

(example: hit the floor, hit by a falling object, electrical shock, exposure to toxic substance, machinery, etc)

Details of two witnesses of the accident: (to be filled in only in case of Injury, NOT in case of Disease/Medical Condition) WITNESS 1 ID Number Name Surname WITNESS 2 _{ID Number} Name Surname Applicant's Declaration I, the undersigned, confirm:

a) that I was injured at work / am suffering from a work-related disease or medical condition, b) that information provided in the above sections are correct, and

c) in the case of an injury, I have not yet returned to work after my injury.

I know that, in the case of a claim for Injury Benefit, if this claim is not received by the Director (Benefits) within 10 days from the date of injury, I may not be entitled for Benefit.

I authorise the Department of Social Security to pass on the information about my case to the Occupational Health and Safety Authority as required for the compilation of statistics.

Appendix C – Injury Benefit Report – Occupational Disease/Medical Condition

Rapport ta’ Marda / Kunxizzjoni Medika

relatat ma’ Xoġħol

Parti 1: Dettalji tal-Applikant

Numru ID Titlu Kunjom Isem

__________ ___ _______________________ _______________________ Data tat-Twelid ______________ Indirizz ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ __________________________________________

Parti 2: Timtela’

mill-Prinċipal f’każ ta’ persuna mpjegata jew

mill-pulizija f’każ ta’ persuna li timpjega lilha nfisha

[A] Dikjarazzjoni f’każ ta’ mpjegat(timtela’ mill-Prinċipal)

Nikkonferma li l-inċident imsemmi ġara waqt jew minħabba x-xogħol tal-persuna indikata. Jekk id-diżgrazzja ma ġratx minħabba jew fil-kors tal-impjieg, agħti iżjed dettalji.

______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

Dettalji tal-Kumpanija: Isem:

Indirizz:

Numru tat-telefown:

E-mail: Timbru Uffiċjali

Numru tal-P.E.: |__|__|__|__|__|__| Numru tal-VAT: |__|__|__|__|__|__|__|__|

Indika d-daqs tal-intrapriża fit-tabella hawn taħt billi tagħmel sinjal (✓) Daqs tal-Intrapriża

0 impjegati (tinkludi self-employed li ma jħaddmu ’l ħadd magħhom) 1 - 9 impjegati

10 - 49 impjegat 50 - 249 impjegat 250 - 499 imjegat 500 impjegat jew iktar

Daqs tal-intrapriża mhux magħruf

L-impjegat daħal lura għax-xogħol? Iva __ Le __

Jekk IVA, imla wkoll id-dikjarazzjoni li ġejja:

Niddikjara li l-persuna hawn fuq imsemmija reġgħet bdiet taħdem fil- |___|___|_____|

wara li ma rraportatx għax-xogħol minn |___|___|_____| sa |___|___|_____|

_____________________________ |___|___|_____|

Parti 3: Timtela’ f’każ ta’ impjegat fis-Settur Pubbliku

Għall-użu tal-Kap tad-Dipartiment (fejn applikabbli)

Injury / Ordinary Sick Leave approvat (aqta’ fejn ma japplikax).

_____________________________ |___|___|_____|

Parti 4: Timtela’ mit-Tabib li jeżamina lill-persuna mweġġa’

Eżaminajt lill-persuna korruta u niċċertifika li qed tbati mill-kunxizzjoni / marda kif indikat fit-Tabelli A, B u C hawn taħt.

Fl-opinjoni tiegħi l-persuna ser tibqa’ nkapaċi għax-xogħol għall-anqas sa ________ (jiem/ġimgħat/xhur) oħra.

TABELLA A – Mard / Kundizzjonijiet ikkaġunati minħabba xogħol

It-Tabib hu mitlub jindika [✓] t-tip ta’ korrimnet skont it-Tabella. TIP TA’ MARD / KUNDIZZJONIJIET

Cancers Liver Cancer

Cancer of the Nasal Cavity Cancer of the Accessory Sinuses Laryngeal Cancer

Ksur ta’ l-G˙adam Skin Cancer Mesothelioma Bladder Cancer Leukaemia

Precancerious Skin Lesions Respiratory Diseases Asthma Allergic Rhinitis Allergic Alveolitis Nasal Ulcerations Nasal Perforation Chronic Bronchitis Asbestosis

Diffuse Thickening of the Pleura Pleural Plaques

Pleural Effusion

Coal Workers’ Pneumoconiosis Silicosis

Pneumoconiosis associated with Tuberculosis Pneumoconiosis due to other silicates

Byssinosis

Hard Metal Disease Neurological Diseases Carpal Tunnel Syndrome Toxic Encephalophaty Polyneurophaty

Diseases of the Sensory Organs Cataract

Noise-indused Hearing Loss Cardiovascular Diseases Raynaud’s Syndrome Skin Diseases

Allergic Contact Dermatitis Irritant Contact Dermatitis Unspecified Contact Dermatitis Contact Urticaria

Acne

Muscoloskeletal Diseases Arthrosis of the Elbow

Arthrosis of the Wrist Respiratory Diseases Skin Diseases

Degeneration Lesions of the Meniscus (knee) Bursitis of Elbow

Bursitis of the Knee

Tenosynovitis of the Hand and the Wrist Medical Epicondylitis (elbow)

Lateranl Epicondylitis (elbow) Infections Tubercolosis Brucellosis Erysipeloid Hepatitis A Hepatitis B Hepatitis C Hepatitis E

Other Specific Hepatitis HIV

Ancylostomiasis

Additional Infectious Diseases Cholera

Typhoid and Parathyphoid Fever Salmonellosis

Shigellosis

Other Bacterial Intestinal Infection Amoebiasis Tularaemia Anthrax Tetanus Diphteria Erysipelas Borreliosis Ornithosis Avian Chlamydiosis Q Fever Rickettsiosis Poliomyelitis Rabies Haemorrhagic Fever Varicella Measles Rubella Mumps Dermatophytosis Malaria

Coding of the Toxic and Irritant Effects Hemolytic Anaemia

Anemia

Secondary Thrombocytopenia Agranyloctosis and Neutropenia Bronchitis (Acute) or Pneumonitis Pulmonary Oedema

Reactive Airways Dysfunction Syndrome Pulmonary Fibrosis

Toxic Liver Disease

Chronic Renal Failure

Colic and other Gastrointestinal Symptoms

TABELLA B – Severita’ tal-Marda/Kundizzjoni

It-Tabib hu mitlub jindika [✓] t-tip ta’ korrimnet skont it-Tabella. SEVERITY OF THE DISEASE

Severity of the desease unknown Temporary incapacity to work

0 - 3 days lost 4 - 6 days lost 7 - 13 days lost 14 - 20 days lost

At least 21 days lost, but less than 1 month At least 1 month lost, but less than 3 months At least 3 months lost, but less than 6 months 6 months or more lost

Permanent incapacity to work

Permanent incapacity without pension, level of disability unspecified

Level of disability, 9 % or less Level of disability, from 10% to 14% Level of disability from 15% to 19% Level of disability from 20% to 29% Level of disability from 30% to 49% Level of disability, 50% or more or pension

Death

Severity of Diseases not elsewhere mentioned

TABELLA C – GRUPPI TA’ ESPOŻIZZJONI MAGGURI

It-Tabib hu mitlub jindika [✓] t-tip ta’ korrimnet skont it-Tabella. THE MAJOR GROUPS OF EXPOSURE FACTORS

CAUSING THE OCCUPATIONAL DISEASE Chemical Agents

Physical Agents Biological Agents

Biomechanical Exposure Factors Psychosocial Exposure Factors

Industrial Exposure Factors, Materials and Products PRODUCT CONTAINING THE EXPOSURE AGENT WHICH CAUSED THE OCCUPATIONAL DISEASE Absorbent and adsorbent

Adhesives, binding agent aerosal propellants Anti-condensation agents Anti-freezing agents

Anti-set-off and anti-adhesive agents Anti-static agents

Bleaching agents

Cleaning / Washing agents Colouring agents

Complexing agents Conductive agents Construction materials

Corrosion inhibitors Cosmetics Cutting fluids Dustbinding agents Electromechanical components Electroplanting agents Explosives Fertilizers Filters Fixing agents

Flame retardants and extinguishing agents Flotation agents

Flux agents for casting joining materrial Foaming agents

Fuels

Fuel additatives Grinding material Heat transferring agents Hydraulic fluids and additatives Impregnation material

Insulating material Intermediates

Laboratory chemicals Lubricants and additatives Odours agents

Oxidising agents

Paint, lacquers and varnishes Pesticides agricultural

Non-agricultural pesticides and preservatives PH-regulation agents Pharmaceuticals Photochemicals Process regulators Radioactive agents Reducing agents Reprographic agents Semiconductors ikompli ... Firma tat-Tabib

Numru tal-Kunsill Mediku Data

Isem it-tabib b’ITTRI KBAR: Softeners Solvents Stabilizers Surface-active-agents Surface treatment Tanning agents Viscosity adjusters Vulcanising agents

Welding and Soldering agents Domestic animals

Wild animals

Products of animal origin Waste of animal origin Waste water

Pointed or cutting medical material Brittle medical material (glass etc.) Other medical instruments

Products for bacteriology or biology laboratories Blood and other human liquids

Other human tissues Patient

Other use categories

_____________________________ |__|__|__|__|

Isem it-tabib b’ITTRI KBAR Numru tal-Kunsill Mediku

_____________________________ |___|___|_____|