Compensation for Occupational Injuries and Diseases Act, 1993 (Act No. 130 of 1993)

Scale of Fees

Purchase

Annexure A

The Department of Labour: Compensation Fund

MRI Motivation Form for Employee's Injured on Duty

Claim Number:
Employee's Name:
Employees ID No:
Name of Employer:
Date of Accident /Injury:
Type of injury:
Brief description of how injury occurred:
Previous clinic / imaging investigations done, and dates:
Imaging investigation required:
Motivation/Clinical indications for the investigation:
Requesting Doctors Name:

Practice Number:

Date of Referral

This form should preferably be typed