The claim for compensation in respect of a workman contracting any disease specified in Part C of Schedule III to the Act shall be supported by a certificate issued by a qualified medical practitioner in the Form “A” appended to these rules:
Provided that where the contracting of such a disease has resulted in death or permanent disablement of the workman the claim shall also be supported by an endorsement on the certificate, in the Form ‘B’ appended to these Rules, by the Medical Board, and in case of difference of opinion between the qualified medical practitioner and the Medical Board, the opinion of the Medical Board shall prevail.
FORM A Certificate of disability by death (See Rule 7) This is to certify that Sri son of aged years is suffering from pneumoconiosis/pneumoconiosis pulmonary tuberculosis, and the contracting of the disease is/was reasonably attributable to his employment in
(1) Temporary disablement.- (a) The disability is in my opinion of a temporary nature likely to last for years/months.
(b) He is fit for work in his present employment / fit for (state employment for which he is considered fit)
(2) Permanent disablement.- The disability is of a permanent nature and is assessed at percent.
(3) Death.- Death is attributable to the contracting of the disease.
(Cancel out portions not applicable) Place:
Date: Signature of the qualified Medical Practitioner FORM B Endorsement to be made by Medical Board in cases of permanent disability or death This is to certify that Sri is/was suffering from pneumoconiosis/pneumoconiosis pulmonary tuberculosis, and the contracting of the disease is/was reasonably attributable to his employment in
(1) Permanent disability.- It is certified that the disability is of a permanent nature and is assessed at percent.
(2) Death.- It is certified that the death of Sri is attributable to the contracting of the disease.
Place:
Date: Signature of Members of Medical Board NOTE:- The Medical Board may call for any further information that may be considered necessary by it from the Medical Practitioner concerned before countersigning certificate in case of death.