Approved form AF2002-90

made under the
Workers Compensation Act 1951

Workers Compensation Act 1951—Form 3

Australian Capital Territory
Workers Compensation Act 1951
Report of medical referee or medical practitioner

I, 				, *a Medical Referee appointed under the Workers Compensation Act 1951 or *a duly qualified medical practitioner, have this day examined 			of				, a claimant for compensation.

On examination—
I find that the claimant is suffering from					.
The above-mentioned condition is the result of				.

The claimant is thereby incapacitated at present to the extent of		per cent of total incapacity at his or her usual occupation and	per cent of total incapacity in the general labour market.

The claimant is fit to undertake employment in such occupations as—

In my opinion the claimant *has/*has not previously suffered from the abovementioned disease.
The disease *is/is not of such a nature as is contracted by a gradual process.

General remarks—

* Medical Referee.
* Medical Practitioner.

Date		/	/20	.

*  Strike out whichever is inapplicable
Fully describe claimant’s condition
State whether accident or disease

Endnotes
1	This form was originally in the Workers Compensation Regulations 1946, schedule 1.  Under amendments made by the Legislation (Consequential Amendments) Act 2001, the form was omitted from the regulations and became a form approved under the Workers Compensation Act 1951, section 222 (see amdt 1.4383, amdt 1.4391).
2	This republication includes amendments made under the Legislation Act 2001, part 11.3 (Editorial changes).

©  Australian Capital Territory 2002