Approved form AF2002-179

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 54
(see r 57 (10) and (11))
Form of medical certificate to be obtained by worker residing out of Australia
[Heading as in award or memorandum.]
I [name, address, and medical qualification of medical practitioner]		certify that I have this day examined A.B.			of		   , whom I conscientiously believe to be the same person as A.B.			                    of			, described in the copy certificate of the medical referee in this matter, dated 							    , and in the certificate of identity dated 					  produced to me by A.B.			    ; and that in my opinion the incapacity of A.B.			   resulting from the injury described in the said certificate of the medical referee still continues.
Dated:
								              [Signature.]
Declared at 		        this			day of			     , in the presence of A.B.			            , the copy of the certificate of the medical referee and the certificate of identity being at the same time produced.
Before me—
[Signature and description of person before whom the 			
declaration is made.]

Endnotes
1	This form was originally in the Workers Compensation Rules 1938, schedule 1.  Under amendments made by the Legislation (Consequential Amendments) Act 2001, the form was omitted from the rules and became a form approved under the rules, rule 89 (see amdt 1.2805, amdt 1.2807).
2	This republication includes amendments made under the Legislation Act 2001, part 11.3 (Editorial changes).

©  Australian Capital Territory 2002