REGULATIONS UNDER THE COMMONWEALTH EMPLOYEES’ COMPENSATION ACT 1930-1944.*
I, THE GOVERNOR-GENERAL in and over the Commonwealth of Australia, acting with the advice of the Federal Executive Council, hereby make the following Regulations under the Commonwealth Employees’ Compensation Act 1930-1944.
Dated this twenty-first day of February, 1945.
HENRY
Governor-General.
By His Royal Highness’s Command,
J. B. CHIFLEY
Treasurer.
Employees’ Compensation Regulations.
Citation.
These Regulations may be cited as the Employees’ Compensation Regulations.
Definitions.
2.—(1.) In these Regulations, unless the contrary intention appears—
“authority” means an authority under the Commonwealth specified in regulation 14 of these Regulations;
“the Act” means the Commonwealth Employees’ Compensation Act 1930-1944.
(2.) Any reference in these Regulations to a Form shall be read as a reference to a Form in the Schedule to these Regulations.
Claim by employee.
Any employee claiming compensation under the Act shall deliver or send by post to the Permanent Head or Chief Officer of the Department or authority in or by which the employee was employed at the time at which the claim arose, or to the officer in charge of the work on which the employee was so employed, a claim for compensation in accordance with Form A.
Claim by dependant.
Any dependant claiming compensation under the Act in respect of the death of an employee shall deliver or send by post to the Permanent Head or Chief Officer of the Department or authority in or by which the employee was employed at the time at which the claim arose, or to the officer in charge of the work on which the employee was so employed, a claim for compensation in accordance with Form B.
Fees to medical referees.
The fees payable to a medical referee shall be as follows:—
£
s.
d.
For a first examination...............................
2
2
0
For a subsequent examination..........................
1
1
0
* Notified in the Commonwealth Gazette on 1st March, 1945.
2873.—Price 8d.
Medical examinations.
6. The medical referee, medical practitioner, or medical board to whom or to which any matter is referred, shall give a certificate in accordance with Form C and shall forward that certificate to the Commissioner or his delegate as soon as possible after the examination.
Frequency of medical examinations.
Where an employee has made a claim for compensation or is in receipt of weekly payments under the Act, he shall not be required, after a period of one month has elapsed from the date on which the first payment of compensation was made, to submit himself against his will for examination by a medical referee, a medical board, or a medical practitioner provided and paid by the Commonwealth, except at reasonable hours, and not at more frequent intervals than once a week during the second month, once a month during the third, fourth, fifth, and sixth months after the date of the first payment, and thereafter once in every two months.
Nomination by employee of representative on medical board.
Where an employee is required by the Commissioner in pursuance of section 19 of the Act to submit himself for examination by a medical board, any nomination by the employee of a medical practitioner as one of the members of the board shall be lodged with the Commissioner within seven days of the date of the notification by the Commissioner to the employee requiring him to submit himself for examination.
Appointment of medical boards.
9. The Commissioner may, from time to time, appoint such medical boards as are required.
Election under section 15 of the Act.
An employee may make an election under section 15 of the Act in accordance with Form D.
Appeals.
11.—(1.) An appeal under section 20 of the Act may be instituted by notice of appeal in accordance with this regulation.
(2.) The person appealing shall, within thirty days after the determination or action appealed against is made or taken, serve the notice of appeal on the Commissioner and shall file a copy of the notice of appeal in the County Court.
(3.) The notice of appeal shall state the grounds of appeal.
(4.) Any person who intends to apply to the Court for extension of the time for appeal shall serve on the Commissioner not less than seven days’ notice of his intention so to apply.
(5.) Where, upon any such application, the Court extends the time for appeal, the person appealing shall serve on the Commissioner the notice of appeal together with a copy of the Order of the Court extending the time for appeal.
(6.) Unless the Court otherwise orders, the date fixed for the hearing of the appeal shall be not less than thirty days after the service on the Commissioner of the notice of appeal.
Costs of appeal.
12.—(1.) The allowance of costs of and incidental to an application for an extension of the time for appeal, or to any appeal, under section 20 of the Act (including an adjournment), to be paid by one party to another, shall be in the discretion of the Court to which the application or appeal is made, and the Court shall have full power to allow or disallow the costs.
(2.) Where a Court allows costs in pursuance of sub-regulation (1.) of this regulation, it shall make an order directing by whom and to whom the costs are to be paid, and, if the amount of the costs is not fixed by agreement between the parties, the Court shall fix the amount of the costs, or direct that the amount be fixed by the Taxing Officer of the Court, in accordance with the provisions of sub-regulation (3.) of this regulation.
(3.) The amount of costs shall be fixed in accordance with the following provisions:—
(a) The fees which may be allowed to a solicitor or counsel or to solicitor and counsel shall not exceed the amounts set out in the following scale:—
£
s.
d.
Instructions for application for extension of time for appeal, preparing, serving and filing notice of application, and all other services in connexion with the application rendered prior to the hearing of the application
1
1
0
Instructions to oppose application for extension of time for appeal and all other services in connexion with the opposition thereto rendered prior to the hearing of the application
1
1
0
Attendance of solicitor or counsel, or solicitor and counsel, on hearing of application
1
1
0
Instructions to appeal, preparing, filing and serving notice of appeal, and all other services in connexion with the appeal rendered prior to the hearing of the appeal
2
2
0
Instructions to oppose appeal including all services in connexion with the opposition thereto rendered prior to the hearing of the appeal
2
2
0
Attendance of solicitor or counsel or solicitor and counsel on hearing of appeal—
For first five hours or portion thereof
5
5
0
For each subsequent hour or portion of an hour........
1
1
0
Any other necessary appearance before the Court of solicitor or counsel or solicitor and counsel
1
1
0
Preparing Bill of Costs for taxation, serving and filing Bill, attending taxation and for allocatur and all other services rendered in connexion with the taxation of costs
0
13
4;
2873.—2
(b) Expenses and mileage for the attendance of parties or witnesses may be allowed at rates not exceeding the rates ordinarily allowable for the attendance of parties and witnesses in an action in the Court; and
(c) Disbursements which in the opinion of the Court or the taxing officer have been properly made may be allowed.
(4.) An order for the payment of costs made by the Court in pursuance of this regulation shall have the same force and effect in all respects as a judgment of the Court and the like proceedings (including proceedings in bankruptcy) may be taken upon the order as if it had been a judgment of the Court for the amount of the costs.
(5.) In this regulation “Taxing Officer” means the Registrar, Clerk of the Court or other person having power to tax the costs of an action in the Court.
Payment of compensation to trustees.
13.—(1.) In cases where the Act provides that any amount of compensation shall be paid to the Commissioner and invested or applied or dealt with by him in such manner as he thinks fit for the benefit of the persons entitled thereto, the amount may be paid to such trustee or trustees as the Commissioner appoints, and the amount so paid shall be held for the benefit of the persons entitled thereto upon such trusts as are approved by the Commissioner.
(2.) Where any determination is varied by the Commissioner in pursuance of paragraph 9 of the First Schedule to the Act, any trust created under this regulation shall cease and determine as from the date of the variation, and any trust moneys then held shall be dealt with in such manner as the Commissioner directs:
Provided that the determination of a trust by operation of this sub-regulation shall not prejudice any right of action against a trustee in respect of any act or omission occurring prior to the date of the variation.
Commonwealth authorities.
14. The authorities under the Commonwealth to employees of which the application of the Act shall extend shall be as follows:—
Commonwealth Bank of Australia;
Commonwealth Savings Bank of Australia;
Repatriation Commission;
War Service Homes Commissioner;
Commonwealth Railways Commissioner;
Australian Commonwealth Shipping Board;
Commonwealth Council for Scientific and Industrial Research;
Board of Management appointed under the Australian War Memorial Act 1925;
Australian Broadcasting Commission;
Canberra Community Hospital Board;
Rifle Clubs, State Rifle Associations and District Rifle Club Unions formed or established in accordance with the Australian Rifle Club Regulations:
Salvage Board;
Australian Potato Committee;
Vegetable Seeds Committee;
Director of Shipping;
War Damage Commission.
Special liability of Commonwealth.
Liability under the Act to pay compensation in respect of personal injury by accident arising out of and in the course of the employment on a rifle range of an employee of a Rifle Club, State Rifle Association or District Rifle Club Union, who is employed in the actual conduct of a rifle practice or competition, shall be borne by the Commonwealth.
Returns by Departments.
The Permanent Head or Chief Officer of each Department and authority shall furnish to the Commissioner not later than the thirty-first day of July, in each year, a correct return in accordance with Form E of payments made under the Act during the twelve months ended on the preceding thirtieth day of June.
Returns by Commissioner to Treasurer.
As soon as possible after the close of each financial year the Commissioner shall furnish to the Treasurer a correct return specifying—
(a) the number of cases in respect of which compensation has been paid under the Act during the previous year;
(b) the amount of compensation paid during that year; and
(c) the amount paid in respect of medical, hospital, and funeral expenses, during that year.
Compliance with forms.
Strict compliance with the forms in the Schedule shall not be required and substantial compliance therewith shall suffice for the purposes of these Regulations.
Declarations.
Declarations under these Regulations may be made before any of the following persons:—
A postmaster or postmistress, or person in charge of a post office, a police, stipendiary or special magistrate of the Commonwealth or of a State, a justice of the peace, a barrister or solicitor, a State school head-teacher, a member of the police force of the Commonwealth or of a State, a legally qualified medical practitioner, a notary public, a commissioner for affidavits, a commissioner for declarations, a minister of religion, a member of the Parliament of the Commonwealth or of a State, or a councillor or alderman of any municipality or shire.
Repeal.
The following Statutory Rules are repealed:—Statutory Rules 1930, No. 134; 1931, Nos. 134 and 143; 1932, No. 143; 1933, No. 141; 1934, No. 79; 1935, No. 33; 1936, Nos. 30 and 160; 1940, No. 157; and 1942, No. 528.
I, [here write full name] of [here write full postal address] hereby claim compensation under the above-mentioned Act in respect of personal injury sustained by me and arising out of and in the course of my employment by the
Commonwealth and declare that, to the best of my knowledge and belief, the following replies to the questions and requests for information are true and correct in every particular:—
Questions and Requests for Information.
Replies.
On date of injury you were employed:—(a) In what precise capacity?....................(b) By what Department or Authority?..............
If you are claiming in respect of incapacity arising from injury by accident:—(a) What is the nature of your injury?.............(b) At what hour did injury occur?...............(c) On what date did injury occur?...............(d) Where did injury occur?....................(e) Describe briefly how injury was caused?.........(f) Were you incapacitated for work?..............(g) On what date were you incapacitated for work?.....(h) Give names of any persons who were present at time of accident or immediate afterwards(i) If accident occurred whilst travelling to or from work, give particulars of journey
If you are claiming in respect of incapacity arising from an industrial disease:—(a) What is nature of disease?...................(b) When was disease caused?..................(c) When were you first incapacitated by such disease?..(d) For what period were you engaged in your employment ?(e) If you have previously suffered from such disease, state:—(i) Approximate date on which such disease first manifested itself(ii) Extent to which such disease interfered with your employment
Was notice of accident or incapacity served?............On whom was notice served?......................On what date was notice served?....................
Have you engaged in any employment since that date of your injury or incapacity?If so, give full particulars.......................
If this claim is made more than six months after occurrence of accident or incapacity, give reasons for failure to make claim within that period
Are you receiving or entitled to receive any payment allowance or benefit under any law other than Commonwealth Employees’ Compensation Act 1930-1944 in respect of your incapacity?If so, give particulars.........................
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:1pt"><td colspan="4" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Questions and Requests for Information.</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Replies.</span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-left:14.4pt; margin-bottom:3pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you a claim against the Commonwealth or any person for compensation, or for any payment (other than payment under an insurance policy privately effected by you or from a friendly society), in respect of the injury under any other law in force in the Commonwealth or any other place?</span><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Give particulars of one of following:—</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">(</span><span style="font-family:'Times New Roman', serif; font-style:italic">a</span><span style="font-family:'Times New Roman', serif">)</span><span style="font-family:'Times New Roman', serif; font-style:italic"> </span><span style="font-family:'Times New Roman', serif">wife of employee; or</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">(</span><span style="font-family:'Times New Roman', serif; font-style:italic">b</span><span style="font-family:'Times New Roman', serif">)</span><span style="font-family:'Times New Roman', serif; font-style:italic"> </span><span style="font-family:'Times New Roman', serif">adult female caring for any child of employee; or</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">(</span><span style="font-family:'Times New Roman', serif; font-style:italic">c</span><span style="font-family:'Times New Roman', serif">) female member of employee</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">’</span><span style="font-family:'Times New Roman', serif">s family over 16 years of age</span><span style="width:29.97pt; text-indent:0pt; display:inline-block"></span></p><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Is she totally or mainly dependent on employee at date of injury?</span><span style="width:1.78pt; text-indent:0pt; display:inline-block"></span></p><p style="margin-left:14.4pt; margin-bottom:3pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">If not, state extent of dependence</span><span style="width:110.51pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">................</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="border-bottom:0.75pt solid #000000; vertical-align:top"></td></tr><tr style="height:1pt"><td style="width:33.18%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Full name of each child under sixteen years of age dependent on employee.</span></p></td><td style="width:7.26%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Age.</span></p></td><td style="width:9.28%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Date of birth.</span></p></td><td colspan="2" style="border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Relationship to employee.</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">State whether totally, mainly or partially dependent on employee at date of injury.</span></p></td></tr><tr style="height:116.7pt"><td style="width:33.18%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:7.26%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:9.28%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:0pt"><td style="width:151.15pt"></td><td style="width:33.05pt"></td><td style="width:42.25pt"></td><td style="width:43.35pt"></td><td style="width:38.7pt"></td><td style="width:124.7pt"></td><td style="width:22.25pt"></td></tr></tbody></table>
I, [here write full name] of [here write full postal address] hereby claim compensation under the above-mentioned Act for myself and children named below in respect of the death of [here write full name of deceased employee] and
declare that, to the best of my knowledge and belief, the following replies to the questions and requests for information are true and correct in every particular:—
Questions and Requests for Information.
Replies.
On date of injury, above-named employee was employed:—(a) In what precise capacity?.................(b) By what Department or Authority?...........
If death of employee was caused by injury by accident:—(a) What was nature of injury?................(b) At what hour did injury occur?.............(c) On what date did injury occur?.............(d) Where did injury occur?..................(e) Describe briefly how injury was caused........(f) Give names of any persons who were present at time of accident or immediately afterwards.(g) If accident occurred whilst employee was travelling to or from work, give particulars of journey.
If death of employee was caused by an industrial disease:—(a) What was nature of disease?...............(b) When was disease caused?................(c) When was employee first incapacitated by such disease?(d) For what period was employee engaged in his employment?(e) If employee ever previously suffered from such disease, state:—(i) Approximate date on which such disease first manifested itself(ii) Extent to which such disease interfered with his employment
Was notice of accident or incapacity served?..........On whom was notice served?....................On what date was notice served?..................
What is your relationship to deceased employee?.......
Were you wholly dependent upon employee’s earnings at date of his death?
Were you in part dependent upon employee’s earnings at date of his death?If so, give full particulars.....................
Was any other person contributing towards your maintenance at date of employee’s death?If so, give full particulars.....................
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:1pt"><td colspan="4" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Questions and Requests for Information.</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Replies.</span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Were you in receipt of a pension or other payment (other than Child Endowment) from the Commonwealth at the date of employee</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">’</span><span style="font-family:'Times New Roman', serif">s death?</span><span style="font-family:'Times New Roman', serif"></span></p><p style="margin-top:12pt; margin-left:21.6pt; margin-bottom:12pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">If so, give particulars</span><span style="width:145.93pt; font-family:'Lucida Console', monospace; display:inline-block">......................</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Did you at date of employee</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">’</span><span style="font-family:'Times New Roman', serif">s death have any other means of support?</span><span style="width:13.66pt; text-indent:0pt; display:inline-block"></span></p><p style="margin-top:12pt; margin-left:21.6pt; margin-bottom:12pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">If so, give full particulars</span><span style="width:127.91pt; font-family:'Lucida Console', monospace; display:inline-block">...................</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-left:14.4pt; margin-bottom:3pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Are you receiving or entitled to receive any payment under any law other than </span><span style="font-family:'Times New Roman', serif; font-style:italic">Commonwealth Employees</span><span style="font-family:'Times New Roman', serif; font-style:italic; font-variant:small-caps">’</span><span style="font-family:'Times New Roman', serif; font-style:italic"> Compensation Act </span><span style="font-family:'Times New Roman', serif">1930-1944 in respect of death of aforesaid employee?</span><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-left:14.4pt; margin-bottom:3pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you a claim against Commonwealth or any person or for any payment (other than a payment under an insurance policy privately effected by deceased employee or from a friendly society) in respect of injury under any law in force in Commonwealth or any other place?</span><span style="font-family:'Times New Roman', serif; font-style:italic"></span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-left:14.4pt; margin-bottom:3pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Give names, addresses and relationships to deceased employee of all other persons (except children) known to you, who were dependent upon his earnings at date of his death.</span><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-left:14.4pt; margin-bottom:3pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">If this claim is made more than six months after occurrence of accident or incapacity, give reasons for failure to make claim within that period.</span><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="border-bottom:0.75pt solid #000000; vertical-align:top"></td></tr><tr style="height:1pt"><td style="width:31.76%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Full name of each child dependent upon deceased employee.</span></p></td><td style="width:7.14%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Age.</span></p></td><td style="width:9.38%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Date of birth.</span></p></td><td colspan="2" style="border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Relationship to deceased employee.</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">State whether wholly or partially (giving full particulars) dependent on earnings of employee at date of his death.</span></p></td></tr><tr style="height:141.25pt"><td style="width:31.76%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:7.14%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:9.38%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:0pt"><td style="width:144.7pt"></td><td style="width:32.5pt"></td><td style="width:42.7pt"></td><td style="width:51.35pt"></td><td style="width:31.15pt"></td><td style="width:129.35pt"></td><td style="width:23.7pt"></td></tr></tbody></table>
REPORT OF MEDICAL REFEREE, MEDICAL BOARD OR MEDICAL PRACTITIONER.
*I/We *Medical Referee
a Medical Board under the Medical Practitioner
Commonwealth Employees’ Compensation Act, have this day examined of , whose signature appears in the margin of this Form, a claimant for compensation under the above-named Act. On examination—
*I/We find that claimant is about years of age and is suffering from (a)
Image unavailable in extracted textThe above condition is the result of (b) , and is such that the claimant is thereby incapacitated at present to the extent of per cent. of total incapacity at his employment at the date of the injury, and per cent. of total incapacity in the general labour market. Claimant is fit to undertake employment in such occupations as
(c) The above condition is the result of (d) an industrial disease mentioned in the first column of the Second Schedule to the above-named Act. Such disease *was/was not caused within twelve months (e) prior to the date of claimant’s becoming incapacitated by his employment by the Commonwealth in the process of
In *my/our opinion claimant *has/has not previously suffered from the above-mentioned industrial disease. The disease *is/is not of such a nature as is contracted by a gradual process.
General Remarks—
*Medical Referee.
Medical Board.
Medical Practitioner.
Date , 19 .
* Strike out what is inapplicable.
(a) Fully describe claimant’s general condition.
(b) State whether accident or industrial disease.
(c) This part to be filled in only in case of claimant suffering from an industrial disease.
(d) The description of the disease must agree with that stated in the Second Schedule.
(e) In the case of Epithelioma of the skin, Silicosis, Pneumoconiosis or Fibrosis of the lungs due to dust, state approximate period within which disease was caused.
Attention is invited to the provisions of the Second and Third Schedules to the Act, copies of which are shown on the back of this form.
Note.—Before making an election the employee should make himself fully acquainted with the compensation or other benefits provided for under the relative determination by the Public Service Arbitrator and under the Commonwealth Employees’ Compensation Act 1930-1944.
I, of , being a person entitled to elect to take compensation or benefits under the Commonwealth Employees’ Compensation Act 1930-1944 or under the provisions of a determination made by the Public Service Arbitrator appointed under the
Arbitration (Public Service) Act 1920-1934 in respect of personal injury by accident arising out of and in the course of my employment by the Commonwealth, hereby elect to take compensation or benefits under the Commonwealth Employees’ Compensation Act 1930-1944.
RETURN OF PAYMENTS MADE DURING THE YEAR ENDED 30th JUNE, 19
Department or Authority State .
£
s.
d.
Amount paid under First Schedule (General)—
(a) in cases of incapacity.....................
£
(b) in cases of death.........................
£
2. Amount paid under Second Schedule (Industrial Diseases)—
(a) in cases of incapacity.....................
£
(b) in cases of death.........................
£
3. Amount paid under Third Schedule (Specified Injuries)—
4. Amount paid in respect of medical, surgical, hospital and funeral expenses.
(The amount here given should not be included under (1), (2), or (3).)
Total amount of compensation paid under the Act during the year—
[
Number of injuries in respect of which compensation has been paid under the Act during the year. (The number here given should not include any injury in respect of which an amount of payment has been included in a previous return)
Permanent Head or Chief Officer of the Department or Authority.
Date
Note.—Payments made under the Arbitration Determinations or under any other Act should not be included in this return.
By Authority: L. F. Johnston, Commonwealth Government Printer, Canberra.