S.I. No. 188/1934 -- Workmen's Compensation Act, 1934 (Certifying Surgeons and Medical Referees) Order, 1934.

S.I. No. 188/1934 -- Workmen's Compensation Act, 1934 (Certifying Surgeons and Medical Referees) Order, 1934. 1934 188

No. 188/1934:

WORKMEN'S COMPENSATION ACT, 1934 (CERTIFYING SURGEONS AND MEDICAL REFEREES) ORDER, 1934.

THE WORKMEN'S COMPENSATION ACT, 1934 (CERTIFYING SURGEONS AND MEDICAL REFEREES) ORDER, 1934, MADE BY THE MINISTER FOR INDUSTRY AND COMMERCE ON THE 28th DAY OF JULY, 1934, PURSUANT TO SECTIONS 76 AND 77 OF THE WORKMEN'S COMPENSATION ACT, 1934 (No. 9 of 1934).

WHEREAS it is enacted by sub-section (1) (vi) of Section 76 of the Workmen's Compensation Act, 1934 , that if an employer or workman is aggrieved by the action of a certifying or other surgeon in giving or refusing to give a certificate of disablement or in suspending or refusing to suspend a workman for the purpose of the said section, the matter shall in accordance with regulations made by the Minister for Industry and Commerce be referred to a medical referee.

AND WHEREAS it is enacted by sub-section (4) of Section 77 of the said Act that the Minister for Industry and Commerce may with the consent of the Minister for Finance make rules regulating the duties and fees of certifying and other surgeons (including dentists) under Part X of the said Act.

AND WHEREAS the Minister for Finance has given the necessary consent.

NOW, THEREFORE, the Minister for Industry and Commerce in exercise of the powers conferred on him by sub-section (1) (vi) of Section 76 and sub-section (4) of Section 77 of the said Act and of every and any other power him in this behalf enabling by this Order makes the following regulations, that is to say:—

1. This Order may be cited for all purposes as the Workmen's Compensation Act, 1934 (Certifying Surgeons and Medical Referees) Order, 1934.

2. The Interpretation Act, 1923 (No. 46 of 1923) applies to the interpretation of this Order in like manner as it applies to the interpretation of an Act of the Oireachtas.

3. In this Order—

(i) "The Act" means the Workmen's Compensation Act, 1934 (No. 9 of 1934).

(ii) "Workman" means a workman as defined in Section 5 of the Act.

(iii) "Certifying Surgeon" means either the certifying surgeon mentioned in sub-section (1) (a) of Section 76 of the Act, or a medical practitioner appointed by the Minister under sub-section (3) of Section 77 to have the powers and duties of a certifying surgeon under the said section.

(iv) "Appointed Surgeon" means a surgeon having power, in pursuance of any special rules or regulations made under the Factory and Workshop Act, 1901, to suspend a workman from employment in the process or processes specified in such rules or regulations.

(v) "Medical Referee" means a medical practitioner appointed by the Minister to act as medical referee for the purposes of Part X of the Act.

(vi) The words "disease to which the Act applies" mean a disease mentioned in the sixth schedule to the Act or a disease or injury (not being an injury by accident) to which the provisions of Part X of the Act have been extended by an Order made by the Minister under sub-section (3) of Section 76 of the Act.

(vii) Words or expressions defined in the Act shall have the same meaning where they occur in this Order as in the Act.

Form 1.

Form 2.

4. Where a workman applies to a certifying surgeon for a certificate (hereinafter called "a certificate of disablement") that he is suffering from a disease to which the Act applies, and is thereby disabled from earning full wages at the work at which he was employed, the certifying surgeon, on payment of the prescribed fee, and after obtaining the particulars specified in the schedule to these regulations and such further information, if any, respecting the case as in the particular circumstances he may deem necessary, shall either proceed at once, if the application is made by the workman in person, to make a medical examination of the workman, or shall appoint forthwith a time and place for making such examination, and give notice thereof to the workman. Such notice, if given in writing, shall follow, as closely as may be, the form prescribed in the schedule.

Forms 3 and 5.

5. After personally examining the workman, the certifying surgeon shall either give the workman a certificate of disablement or shall certify that he is not satisfied that the workman is entitled to such certificate, and shall in either case deliver his certificate to the workman. The certificate given shall be in the form prescribed in the schedule to these regulations.

Forms 6 and 8.

6. Where, in pursuance of any special rules or regulations made under the Factory and Workshop Act, 1901, the certifying or appointed surgeon, after having personally examined a workman, suspends him from his usual employment on account of his having contracted any disease to which the Act applies, or where in the case of a workman applying to be suspended on account of his having contracted any such disease, the surgeon as aforesaid, after having personally examined such workman, refuses to order his suspension, he shall, on the application either of the employer or of the workman, and on payment of the prescribed fee, certify such suspension or refusal to suspend in accordance with the form prescribed in the schedule to these regulations, and shall deliver such certificate to the applicant.

See Forms 4 and 7.

7. Where a certificate of disablement is given or a workman is suspended, and the case is one in which, under the provisions of subsection (1) of Section 77 of the Act as extended by any Order of the Minister made under sub-section (3) of Section 76 of the Act the disease contracted by the workman will be deemed, unless the employer proves, or the certifying surgeon certifies, to the contrary, to have been due to the nature of the employment in the process in which at or immediately before the date of the disablement or suspension the workman was employed, the certifying surgeon, if he is of opinion that the disease contracted by the workman was not due to the nature of such employment, shall certify accordingly. Such certificate shall, where possible, be given simultaneously with, and included in, the certificate of disablement or the certificate (if any) of suspension, but may also be given separately on application by the employer and on payment of the prescribed fee; and in either case shall follow the form prescribed in the schedule to these regulations.

For the purposes of this regulation an appointed surgeon shall have the same powers and duties as a certifying surgeon.

8. A copy of any certificate given by a certifying or appointed surgeon under the foregoing regulations shall, together with any other documents relating to the case, be retained and kept by the surgeon; and copies of any such certificate shall, on payment of the prescribed fee, be supplied by the surgeon to the employer and the workman.

9. The fees which the certifying and appointed surgeons shall be entitled to charge in respect of duties performed under Part X of the Act shall be as follows:—

FEES PAYABLE BY THE WORKMAN.

(i) For any certificate given under Regulation 5—

(a) in cases where the medical examination of the workman is made by the surgeon in the performance of his duties under the Factory and Workshop Act, 1901, a fee of 1s.

(b) in all other cases, a fee of 5s., and where the workman is unable to present himself for examination at the residence of, or other nearer place fixed by, the certifying surgeon, for every mile or portion thereof which the certifying surgeon is required to travel therefrom for the purpose of examining the workman, an additional fee of 1s.

(ii) For any certificate of suspension or refusal to suspend, under Regulation 6, when the medical examination of the workman is made in pursuance of any special rules or regulations under the Factory and Workshop Act, 1901, a fee of 1s.

(iii) For a copy of any certificate obtained under Regulation 8 a fee of 1s.

FEES PAYABLE BY THE EMPLOYER.

(iv) For any certificate of suspension or refusal to suspend, obtained by the employer under Regulation 6, a fee of 1s.

(v) Where the employer applies under Regulation 7 for a certificate that the disease contracted is not due to the nature of the employment, in respect of every such application (to include the certificate, if given), a fee of 2s. 6d.

(vi) For a copy of any certificate obtained under Regulation 8, a fee of 1s.

REFERENCES TO MEDICAL REFEREES.

10. Where an employer or workman is aggrieved by the action of a certifying or appointed surgeon in giving or refusing to give a certificate of disablement or in suspending or refusing to suspend a workman, he may—

(a) if he is an employer, within ten days of the receipt of the notice of disablement or suspension required to be given under the Act, or, in a case of disablement, if the notice is not accompanied by the certificate of the surgeon, or a copy thereof, and the employer forthwith requires the workman to furnish him with a copy, within ten days of the receipt of such copy, or

(b) if he is a workman, within ten days of the date on which the surgeon has refused to give him a certificate of disablement or suspension,

apply to the registrar of the circuit court for the district in which the workman was employed at the time of his examination by the surgeon, for the matter to be referred to a medical referee; provided that it shall be within the discretion of the registrar, on good cause shown, to extend in any case by not more than seven days the period within which an application is required to be made.

Forms 9 and 10.

11.—(a) Any application under the foregoing regulations shall be made in writing, and shall state the grounds on which the reference is asked for, in accordance with the form prescribed in the schedule to these regulations, or as near thereto as may be.

(b) The application shall be accompanied by the certificate or a copy of the certificate obtained from the surgeon by whose action the applicant is aggrieved, and by any available report or reports of any medical practitioner by whom the workman has been examined; and if the applicant is an employer, by the notice of disablement or suspension served on him by the workman, and by an undertaking to pay any reasonable travelling expenses incurred by the workman in attending for examination by the medical referee.

(c) The applicant shall also file with the registrar such copies of the application and other documents as aforesaid as may be necessary for the use of the medical referee and of the employer or workman, as the case may be, hereinafter referred to as the respondent, who together with the applicant is directly interested in the application.

(d) In the event of any dispute as to the amount of the travelling expenses payable to the workman by the employer, the matter may be referred to the registrar, whose decision shall be final.

Form 11.

12. It shall be the duty of the registrar on receiving an application to satisfy himself that it is duly made in accordance with the foregoing regulations, and if it is not, to return it for amendment. If and when the application is in accordance with the regulations, he shall refer the matter forthwith to a medical referee, and shall forward to such medical referee by registered post one of the copies of the application and the other documents filed therewith, with an order of reference according to the form prescribed in the schedule.

Form 12.

13. The registrar shall also make an order directing the workman to submit himself for examination by the medical referee. Before making such order the registrar shall inquire whether the workman is in a fit condition to travel for the purpose of examination, and if satisfied that he is in a fit condition shall by the order direct him to attend at such time and place as the referee may fix, and if satisfied that he is not in a fit condition to travel, shall so state in the order of reference; and it shall be the duty of the workman, on being served with the order, to submit himself for examination accordingly.

14. The registrar shall deliver or send by registered post to both parties a copy of the order of reference, and shall also send to the respondent copies of the other documents forwarded to the medical referee, and shall send to the workman a copy of the order directing him to submit himself for examination.

15. In the case of a reference under these regulations, the medical referee shall be one of those appointed by the Minister for the circuit court circuit which includes the district in which the case arises, and if the circuit has been sub-divided and medical referees have been appointed for the sub-divisions, shall be one appointed for the subdivision comprising the aforesaid district. Provided that if any medical referee is or has been specially appointed by the Minister, either for the circuit or otherwise, for the purpose of deciding on any specified case or class of cases in which a reference may be made under these regulations, the reference in any such case shall be made to the medical referee so appointed. Provided also that if the surgeon by whose action the applicant is aggrieved, has been appointed a medical referee, the reference shall not be made to him, but to such other medical referee as may be authorised to act.

Forms 13 and 14.

16. The medical referee shall, on receipt of an order of reference duly signed by the registrar of a circuit court together with copies of the documents required to be sent therewith, fix a time and a place for a personal examination of the workman, and shall send notice to the employer and workman accordingly. It shall be the duty of the workman, and, if the employer is the applicant, of the employer or a person duly authorised by him, to attend at the time and place fixed by the medical referee, and in the event of failure on the part of the workman or employer or both to appear as required by this regulation, the medical referee shall decide on the matter referred to him forthwith upon such information as shall be available and with or without a personal examination. Provided that where the absence of the employer or his representative or of the workman is shown to the satisfaction of the medical referee to be unavoidable, or where the medical referee considers it necessary to apply for expert assistance as hereinafter provided, it shall be open to him to adjourn the inquiry on the reference and to resume it at such time and place as he may fix, after giving due notice to all parties concerned.

17. In cases involving special difficulty the medical referee may apply for special expert assistance which may be granted by the Minister for Industry and Commerce if he thinks fit, on such terms as to remuneration or otherwise as he may with the sanction of the Minister for Finance determine.

18. Except as otherwise provided by Regulation 16, the medical referee shall, before deciding on the matter referred to him, make a personal examination of the workman, and shall consider any statements made or submitted by either party.

Forms 15 (i), 15 (ii) and 15 (iii).

19. The medical referee shall, by certificate, in such one of the forms prescribed in the schedule to these regulations as may be appropriate, notify in writing his decision to the registrar of the circuit court, and give a certificate as to the condition of the workman at the time of his examination.

20. On the receipt of the certificate of the medical referee the registrar shall send copies to the parties by post and shall permit any party to inspect the original during office hours and shall on the application of any party allow him to take a copy thereof.

Form 16.

21. The registrar of a circuit court shall keep a record, in the form prescribed in the schedule, of all references made by him under these regulations, and shall send the same to the Minister at the end of each quarter.

22. This Order shall come into operation on the first day of August 1934.

Given under the official seal of the Minister for Industry and Commerce this 28th day of July, in the year One Thousand Nine Hundred and Thirty-four.

(Signed), JOHN LEYDON,

Secretary.

Department of Industry and Commerce.

SCHEDULE.

(FORM 1)

PARTICULARS TO BE OBTAINED BY CERTIFYING SURGEON UPON APPLICATION BY WORKMAN FOR CERTIFICATE OF DISABLEMENT.

1. Name and address of workman
2. Disease in respect of which certificate is applied for	}
3. Symptoms complained of
4. Employment to the nature of which disease is attributed	}
5. Name and place of business of employment who last employed workman in such employment	}
6. (Where applications is not made by workman in person) whether workman is able to travel for purposes of examination	}

(FORM 2.)

NOTICE TO WORKMAN OF TIME AND PLACE APPOINTED FOR HIS EXAMINATION BY SURGEON.

WORKMEN'S COMPENSATION ACT, 1934 .

I hereby give you notice, with reference to your application for a certificate of disablement under Section 76, sub-section (1), of the above-named Act, that I propose to examine you at........................ on the.........day of.................. at..................o'clock, and that you are required to submit yourself for examination accordingly.

To (the Workman).

(Signed)

(FORM 3.)

CERTIFICATE OF DISABLEMENT.

WORKMEN'S COMPENSATION ACT, 1934 .

I, (a) as certifying surgeon appointed under the Factory and Workshop Act, 1901, for the district of............ (or as a medical practitioner appointed by the Minister for Industry and Commerce to have the powers and duties of a certifying surgeon for the purposes of Part X of the Act), hereby certify that having personally examined (b)..................on the.........day of.................. I am satisfied that (c).................. is suffering from (d).................. being one of the diseases to which the Workmen's Compensation Act applies, and is thereby disabled from earning full wages at the work at which (c)..................) has been employed; and I* certify that the disablement commenced on the......... day of..................

1. Full name and address of workman
2. Process in which workman states he was employed at or immediately before the date of disablement	}
3. Name and place of business of employment stated by workman to have last employed him in process above-mentioned	}
4. leading symptoms of disease
Date this .............................day of...........

(Signed)

(a) strike out portion of description inapplicable.

(b) name of workman.

(d) name disease according to the terms in which it is described in the sixth schedule to the Act or Order of the Minister for Industrial and Commerce adding it to the schedule.

(FORM 4)

CERTIFICATE (SUPPLEMENTARY TO A CERTIFICATE OF DISABLEMENT) TO BE GIVEN BY CERTIFYING SURGEON IN CIRCUMSTANCES MENTIONED IN REGULATION 7.

1. When the certificate is included in the certificate of disablement, it should run as follows:—

But whereas the said workman appears to have been employed at or immediately before the date of disablement in (a).....................being a process (b).....................the second column of the sixth schedule to the Act, and the disease contracted by him, viz. (c) ..................is a disease which (d)..................is set opposite the above-mentioned process, I hereby certify that in my opinion the said disease is not due to the nature of such employment.

Dated this.........day of..................

(Signed)

2. When the certificate is given separately on a subsequent application of the employer, it should be in the following form:—

WORKMEN'S COMPENSATION ACT, 1934 .

Whereas I, (e) the certifying surgeon appointed under the Factory and Workshop Act, 1901, for the district of..................(or as a medical practitioner appointed by the Minister for Industry and Commerce to have the powers and duties of a certifying surgeon, for the purposes of Part X of the above-named Act), on the.........day of..................certified that (f).....................was suffering from (g)..................being a disease to which the Workmen's Compensation Act applies, and was thereby disabled from earning full wages at the work at which he was employed; and whereas the said (f)...............appears to have been employed at or immediately before the date of disablement in (h)..................being a process (i)..................the second column of the sixth schedule to the Act, and the disease above-named is a disease which (k).....................is set opposite the above-mentioned process, I hereby certify that, in my opinion, the said disease was not due to the nature of such employment.

Dated this.........day of..................

(Signed)

(a) name process.

(b) "mentioned In" or "added by an Order of the Minister for Industry and Commerce to."

(d) "in the first column of that schedule" or "under the provisions of the said Order."

(e) strike out, portion of description inapplicable.

(f) name of workman.

(g) name disease.

(h) name process.

(i) "mentioned" or "added by Order of the Minister for Industry Commerce to."

(k) "in the first column of that schedule" or "underneath the provisions of the said Order."

(FORM 5.)

CERTIFICATE OF CERTIFYING SURGEON REFUSING TO GIVE CERTIFICATE OF DISABLEMENT.

WORKMEN'S COMPENSATION ACT, 1934 .

I, (a), as certifying surgeon appointed under the Factory and Workshop Act, 1901, for the district of..................(or as a medical practitioner appointed by the Minister for Industry and Commerce to have the powers and duties of a certifying surgeon for the purposes of Part X of the above Act), hereby certify that having personally examined (b)..................who has applied for a Certificate of Disablement in respect of (c)...............being a disease to which the Workmen's Compensation Act applies, I am not satisfied that (d)..................is suffering from the said disease so as to be disabled from earning full wages at the work at which (d).........has been employed.

1. Full name and address of workman
2. Employment to nature of which disease complained of was attributed	}
3. Name and place of business of employer stated by workman to have last employed him in such employment	}

Dated this......... day of................................

(Signed)............................................................ ...................

(a) strike out portion of description inapplicable.

(b) name workman

(d) " he " or " she."

(FORM 6.)

CERTIFICATE OF SUSPENSION BY CERTIFYING OR APPOINTED SURGEON.

WORKMEN'S COMPENSATION ACT, 1934 .

I, the (a)..................surgeon for (b)..................hereby certify that after personally examining (c).................., I have on the......... day of.................. in pursuance of the (d)..................made under the Factory and Workshop Act, 1901, suspended the said (c)..................from (e).........usual employment on account of (e).........having contracted (f)..................being a disease to which the Workmen's Compensation Act applies.

1. Full name and address of workman
2. Employment to nature of which disease complained of was attributed	}
3. Name and place of business of employer state by workman to have last employed him in such employment	}

Dated this.................day of..................................

(Signed)............................................................ ...

(a) "certifying or "appointed."

(b) name works which workman employed.

(d) name the special rules or regulations governing the employment.

(e) " his "or "her".

( f ) describe disease.

(FORM 7)

CERTIFICATE TO BE GIVEN BY SURGEON IN CASES OF SUSPENSION IN CIRCUMSTANCES MENTIONED IN REGULATION 7

1. When the certificate is included in a certificate of suspension, it should run as follows :—

But whereas the said workman appears to have been employed at or immediately before the date of suspension in (a)..................being a process (b)..................the second column of the sixth schedule to the Act, and the disease contracted by him, viz. (c)..................is a disease which (d)..................is set opposite the above-mentioned process, I hereby certify that in my opinion the said disease is not due to the nature of such employment.

Dated this........day of.............

(Signed)............................................................ ..................................

(a)Name and process.

(b) " mentioned in" or " added by an Order of the Minister for Industry and Commerce to."

(d) " in the first column of that schedule " or " under the provisions of the said order."

2. When the certificate is given separately on an application by the employer, it should be in the following form :—

WORKMEN'S COMPENSATION ACT, 1934 .

Whereas I, the (a)..................surgeon for (b)..................on the.........day of..................in pursuance of the (c)..................made under the Factory and Workshop Act, 1901, suspended (d)..................from (e).........usual employment on account (e).........having contracted (f)..................being a disease to which the Workmen's Compensation Act applies, and whereas the said (d).........appears to have been employed at or immediately before the date of suspension in (g)..................being a process (h)..................the second column of the sixth schedule to the Act, and the disease above-named is a disease which (i)..................is set opposite the above-mentioned process, I hereby certify that in my opinion the said disease was not due to the nature of such employment.

Dated this................................day of..........................

(Signed)............................................................ .......................................

(a) " certifying " or " appointed."

(b) name works at which workman was employed.

(d) name of workman.

(e) " his " or " her."

( f ) describe disease.

(g) name process.

(h) " mentioned in " or " added by an Order of the Minister for Industry and Commerce to."

(i) "in the first column of that schedule" or " under the provisions of the said Order."

(FORM 8.)

CERTIFICATE BY CERTIFYING OR APPOINTED SURGEON OF REFUSAL TO SUSPEND.

WORKMEN'S COMPENSATION ACT, 1934 .

I, the (a)..................surgeon for (b)..................hereby certify that (c)..................having applied to me to be suspended from his usual employment in pursuance of (d)..................made under the Factory and Workshop Act, 1901, on account of (e).........having contracted (f)..................being a disease to which the Workmen's Compensation Act applies, I have after personally examining the said (c)..................refused to suspend (g).........

1. Full name and address of workman

2. Name and place of business of employer

3. Ground for refusal to suspend

Dated this...........................................day of...........................

(Signed)............................................................ ...........................................

(a) " certifying " or " appointed."

(b) name works at which workman is employed.

(d) name the code of special rules or regulations governing the employment.

(e) " his" or " her."

( f ) describe disease

(g) "him" or "her"

(FORM 9.)

APPLICATION BY EMPLOYER FOR REFERENCE TO MEDICAL REFEREE.

In the Circuit Court holden at..................

In the matter of the Workmen's Compensation Act, 1934 ,

and

In the matter of a Certificate of Disablement (or Suspension) granted in the case of..................(name and address of workman) in pursuance of the provisions of Part X of the above-mentioned Act and the regulations made thereunder by the Minister for Industry and Commerce.

Application for a reference in the above-mentioned matter to a medical referee, pursuant to Section 76, sub-section (1)(vi), of the Act and to the above-mentioned regulations, is hereby made on behalf of (name and place of business of applicant) who states :—

1. That on the.........day of..................notice of disablement (or suspension) was given to the applicant by the above-mentioned under the provisions of the said Act.

2. That the said notice was consequent on a certificate of disablement given (or order of suspension made), on the.........day of..................in pursuance of the said Act, and regulations, by Mr..................residing at..................(full address), the certifying Surgeon under the Factory and Workshop Act, 1901, for the district of..................(or a medical practitioner appointed by the Minister for Industry and Commerce to have the powers and duties of a certifying surgeon under Part X of the said Act, or a surgeon appointed in pursuance of..................(describe special rules or regulations under the Factory Act) at..................(name of factory or other place of employment)).

3. That the applicant is aggrieved by the action of the above-mentioned Mr..................in giving the said certificate (or in making the said order of suspension) and claims that the said..................had not contracted the disease in respect of which the said certificate was given (or in respect of which the said order was made) (or, in the case of a certificate of disablement, was not suffering from the disease therein specified so as to be disabled from earning full wages at the work at which he was employed), in support of which claim he mentions the following circumstances :—*

And the applicant hereby undertakes, if the matter is referred to a medical referee, to repay to the said..................(workman) any reasonable travelling expenses he may incur in attending for examination by such referee.

Two copies of this application are annexed hereto, together with a copy of the notice and certificate of disablement (or suspension). The above-mentioned report of the medical practitioner employed by me, and two copies thereof, are also annexed.

Dated this..............................day of.......................

(Signed)............................................................ ..........................................

Applicant.

To the Registrar

*State grounds for claim, eg., report any doctor employed by applicant.

(FORM 10)

APPLICATION BY WORKMAN FOR REFERENCE TO MEDICAL REFEREE.

In the Circuit Court holden at..............................

In the matter of the Workmen's Compensation Act, 1934 ,

and

In the matter of a Refusal of a certifying (or appointed) Surgeon to give a Certificate of Disablement to (or to suspend).................. (name and address of applicant) in pursuance of the provisions of Part X of the above-mentioned Act and the regulations made thereunder by the Minister for Industry and Commerce.

Application for a reference in the above-mentioned matter to a medical referee, pursuant to Section 76, sub-section (1) (vi), of the said Act and to the above-mentioned regulations, is hereby made on behalf of the said..................who states :—

1. That on the.........day of..................applicant applied to Mr..................residing at..................(full address) the certifying surgeon under the Factory and Workshop Act, 1901, for the district of..................(or a medical practitioner appointed by the Minister for Industry and Commerce to have the powers and duties of a certifying surgeon for the purposes of Part X of the said Act, or a surgeon appointed in pursuance of..................(describe special rules or regulations under Factory Act) at..................(name of factory, or other place of employment)), for a certificate of disablement (or to be suspended) in respect of..................a disease to which the provisions of Part X of the Workmen's Compensation Act apply.

2. That the said Mr..................refused to give the applicant a certificate of disablement (or to suspend the applicant) and certified to such refusal by a certificate, dated.........day of.................., which is annexed to this application.

3. That the applicant is aggrieved by the action of the said Mr..................in refusing to give him a certificate of disablement (or to suspend him) and claims that he was suffering from the said disease, and was thereby disabled from earning full wages at the work at which he was employed (or in the case of a refusal to suspend) that he had contracted the said disease and was thereby entitled, in accordance with the special rules (or regulations) made under the Factory and Workshop Act, 1901, for the process in which he was employed, to be suspended), in support of which claim he mentions the following circumstances :—(*)

4. That the employer on whom the applicant, if the matter is referred to a medical referee and decided in favour of the applicant, would serve the statutory notice of disablement (or suspension) is..................(name and place of business of employer).

Two copies of this application and the certificate of the surgeon (together with the above-mentioned report of the medical practitioner employed by applicant and two copies thereof) are annexed hereto.

Dated this...........................day of..........................................

(Signed)............................................................ ............................

Applicant.

To the Registrar.

*State grounds of claim, eg., report, if any, of doctor employed by applicant.

(FORM 11.)

ORDER OF REFERENCE TO MEDICAL REFEREE.

In the Circuit Court holden at....................................

(Heading as in application.)

On the application of..................(a copy of which is hereto annexed), I hereby appoint Mr..................of..................one of the medical referees appointed by the Minister for Industry and Commerce for the purposes of the Workmen's Compensation Act, 1934 , to decide on the matter arising on the said application.

Copies of the notice and certificate of disablement (or suspension), (and of a report of a medical practitioner by whom the workman referred to in the application has been examined), are hereto annexed.

Or, if the workman is the applicant.

A copy of the certificate of the surgeon referred to in the application (together with a copy of a report of a medical practitioner by whom applicant has been examined), is hereto annexed.

The said..................who is now at.................., has been directed to submit himself for examination by the referee.

I am satisfied that the said..................is in a fit condition to travel for the purpose of being examined, and he has been directed to attend on the refered for examination at such time and place as may be fixed by the referee.

[Or the said..................does not appear to be in a fit condition to travel for the purpose of being examined.]

Dated this..................................................day of................................

..................................................Registrar.

(FORM 12.)

ORDER ON WORKMAN TO SUBMIT HIMSELF FOR EXAMINATION BY MEDICAL REFEREE.

In the Circuit Court holden at............................................................ .

(Heading as in application.)

To A.B..................., of..................(address and description).

Take Notice, that I have appointed Mr.................., of..................one of the medical referees appointed by the Minister for Industry and Commerce for the purposes of the Workmen's Compensation Act, 1934 , to decide on the matter arising on the above application.

You are hereby required to submit yourself for examination by the referee [add, where workman is in a fit condition to travel, and to attend for that purpose at such time and place as may be fixed by him.]

Dated this...............................day of..................................

........................................Registrar.

(FORM 13.)

NOTICE BY MEDICAL REFEREE TO WORKMAN.

WORKMEN'S COMPENSATION ACT, 1934 .

I hereby give you notice that I have received from the Registrar of the Circuit Court at.................., an order of reference appointing me to decide on your appeal against the action of Mr.................. (name of surgeon) in refusing to give you a certificate of disablement (or to suspend you).

Or, if the employer is the appellant, on the appeal made by..................(name of employer) against the action of Mr..................(name of surgeon) in giving you a certificate of disablement (or in suspending you);

And that you are required to attend (or, if the workman has been ascertained not to be in a fit condition to travel, to submit yourself) for examination at............on the.........day of..................at..................o'clock

Any statement made or submitted by you shall be considered.

(Signed)............................................................ ..............................

Medical Referee.

To.

(FORM 14.)

NOTICE BY MEDICAL REFEREE TO EMPLOYER.

WORKMEN'S COMPENSATION ACT, 1934 .

I hereby give you notice that I have received from the Registrar of the Circuit Court at.................., an order of reference appointing me to decide on your appeal against the action of Mr.................. (name of surgeon) in giving a certificate of disablement to (or in suspending)..................(name of workman).

Or, if the workman is the appellant, on the appeal made by.................. (name of workman) against the action of Mr..................(name of surgeon) in refusing to give him a certificate of disablement (or to suspend him) ;

And that I propose to examine..................(name of workman) at..................on the.........day of..................at..................o'clock.

Any statement made or submitted by you shall be considered.

Add, if the employer is the appellant,

You, or some person duly authorised by you, are hereby required to attend at the above time and place.

Dated this..........................day of...........................

(Signed)............................................................ ..................................................

Medical Referee.

To.

FORM 15 (i)

DECISION OF MEDICAL REFEREE UNDER SECTION 76 (1) (vi) OF THE WORKMEN'S COMPENSATION ACT, 1934 , DISMISSING AN APPEAL AGAINST THE ACTION OF THE CERTIFYING OR OTHER SURGEON IN GIVING OR REFUSING TO GIVE A CERTIFICATE OF DISABLEMENT, TOGETHER WITH CERTIFICATE OF MEDICAL REFEREE AS TO THE PRESENT CONDITION OF THE WORKMAN.

Decision under Section 76 (1) (vi) of the Workmen's Compensation Act, 1934.

(Heading as in the application for the Reference.)

I hereby give you notice that having duly inquired into the above-mentioned matter in accordance with the Regulations of the Minister for Industry and Commerce, I decide as follows :—

I dismiss the appeal of (name of employer) against the certificate of disablement given to (name of workman) on the day of

I dismiss the appeal of (name of workman) against the certificate issued to him by (name of surgeon) on his application for a certificate of disablement in respect of (name scheduled disease).

Certificate as to workman's present condition.

And I hereby certify that the present condition of the workman as ascertained by my examination is as follows :—*

Dated this day of

(Signed)

Medical Referee.

To the Registrar.

*Here state whether the workman is or is not suffering from the scheduled disease, and in the former case, whether he is thereby disabled from earning full wages at the work at which he was employed, and if so whether he is fit for any other kind of work, specifying where necessary the kind of work for which he is fit. If the Referee finds that the workman is no longer physically incapacitated for work as a result of the attack of the disease, but that the workman's condition is such that either (a) there is a reasonable probability of the workman becoming again incapacitated through a recrudescence of the attack of the disease, or (b) there is, as a result of the attack, an increased susceptibility to a fresh attack of the disease, the Referee should include a statement as to his findings.

If the workman failed to appear for personal examination by the Referee, the Referee should, when giving his decision as above, certify accordingly in the second part of the certificate.

FORM 15 (ii)

DECISION OF MEDICAL REFEREE UNDER SECTION 76 (1) (vi) OF THE WORKMEN'S COMPENSATION ACT, 1934 , ALLOWING AN APPEAL AGAINST THE ACTION OF THE CERTIFYING OR OTHER SURGEON IN GIVING OR REFUSING TO GIVE A CERTIFICATE OF DISABLEMENT, TOGETHER WITH CERTIFICATE OF MEDICAL REFEREE AS TO THE PRESENT CONDITION OF THE WORKMAN.

Decision under Section 76 (1) (vi) of the Workmen's Compensation Act, 1934.

(Heading as in the application for the Reference.)

I hereby give you notice that having duly inquired into the above-mentioned matter in accordance with the Regulations of the Minister for Industry and Commerce, I decide as follows :—

I find that the said (name of workman) was not, at the time of his examination by the Certifying Surgeon, suffering from (name scheduled disease).

I find that the said (name of workman) was, at the time of his examination by the Certifying Surgeon, suffering from (name scheduled disease), but that he was not thereby disabled from earning full wages at the work at which he was employed.

I find that the said (name of workman) was, at the time of his examination by the Certifying Surgeon, suffering from (name scheduled disease), and was thereby disabled from earning full wages at the work at which he was employed. And I fix the day of as the date on which the disablement from the said disease commenced.

Certificate as to workman's present condition.

And I hereby certify that the present condition of the workman as ascertained by my examination is as follows :—*

Dated this day of

(Signed)

Medical Referee.

To the Registrar.

If the workman failed to appear for personal examination by the Referee, the Referee should, when giving his decision as above, certify accordingly in the second part of the certificate.

FORM 15 (iii)

DECISION OF MEDICAL REFEREE UNDER SECTION 76 (1) (vi) OF THE WORKMEN' COMPENSATION ACT, 1934, DISMISSING OR ALLOWING AN APPEAL AGAINST THE ACTION OF THE CERTIFYING OR OTHER SURGEON IN SUSPENDING OR REFUSING TO SUSPEND THE WORKMAN, TOGETHER WITH CERTIFICATE OF MEDICAL REFEREE AS TO THE PRESENT CONDITION OF THE WORKMEN.

Decision under Section 76 (1) (vi) of the Workmen's Compensation Act, 1934.

(Heading as in the application for the Reference.)

I hereby give you notice that having duly inquired into the above-mentioned matter in accordance with the Regulations of the Minister for Industry and Commerce, I decide as follows :—

I dismiss (or allow) the appeal of (name of employer) against the suspension of (name of workman) on the day of on account of his having contracted (name scheduled disease)

I dismiss (or allow) the appeal of (name of workman) against the refusal of (name of surgeon) to suspend him on the day of on account of his having contracted (name scheduled disease).

Certificate as to workman's present condition.

And I hereby certify that the present condition of the workman as ascertained by my examination is as follows :—*

Dated this day of

(Signed)

Medical Referee.

To the Registrar.

If the workman failed to appear for personal examination by the Referee, the Referee should, when giving his decision as above, certify accordingly in the second part of the certificate.

(FORM 16.)

RECORD OF REFERENCES TO BE KEPT BY COUNTY REGISTRAR.

Circuit Court No....................................................... Court holden at............................................................ .....

Name of County Registrar............................................................ ............................................................ ...................

For the quarter ended..............................................

Court Number of Matter	Names of Parties	Action of Surgeon by which applicant is aggrieved	Nature of Disease *	Date on which reference forwarded to Referee	Whether workman directed to attend on Referee or not	Date on which County Registrar received notification of Referee's decision	Name of Medical Referee appointed
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)

* Describe in terms of the Sixth Schedule to the Act or of any Order made under Section 76 (3) of the Act.

Note:—If in any case the fees of the Medical Referree have been or are to be paid otherwise than from the Exchequer, a note to that effect should be appended.

Irish Statutory Instruments

S.I. No. 188/1934 -- Workmen's Compensation Act, 1934 (Certifying Surgeons and Medical Referees) Order, 1934.