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.