Approved form AF2002-152

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 27
(see r 35)
Form of memorandum under the Act, schedule 4, clause 9
	(i)	In case of injury to worker by accident.
To the Registrar of the Magistrates Court, Canberra.
In the matter of the Workers’ Compensation Act 1951,
and
In the matter of an arbitration between [name]					of [address]			[description]		          Applicant,	and [name]								of [address]			[description]		          Respondents.
[Or, where the matter has been decided by agreement without arbitration.]
In the matter of an agreement between [name]					of [address]			[description]				and [name]								of [address]			[description]
Be it remembered, that on 							, personal injury was sustained by the above-named			, a worker under no legal disability, [or a child of the age of			years,] being injury arising out of and in the course of his or her employment.
And that on the								, the following agreement was come to by and between			and				: [or And that on the			      day of		      20          , the following decision was given by a committee representative of the said			     and their workers, having power to settle matters under the above-mentioned Act in the case of				  and their workers]			[or And that on the		               day of			     20    , the following award was made and given by me, the undersigned		, being an arbitrator agreed on by the said		       and the said			, that is to say:]
[Here set out a copy of agreement, decision, or award.]
[If a medical referee has been appointed to report, add—
A copy of the report of			, a medical referee appointed to report in this matter, is annexed.]
[Add, if so, The			attended the arbitration on 			.]
You are requested to record this memorandum, pursuant to the Workers Compensation Act 1951, schedule 4, clause 9.
Dated:
[To be signed in accordance with rule 36 (1), (2).]
Note	This form to be adapted to the circumstances of the case and the matter decided.
	(ii)	In the case of injury to workers by industrial disease.
To the Registrar of the Magistrates Court.
In the matter of the Workers Compensation Act 1951,
and
In the matter of an arbitration between [name]
	of [address]	[description]	Applicant,
	and [name]
	of [address]	[description]	Respondents.
[Or, where the matter has been decided by agreement without arbitration],
In the matter of an agreement between [name]					of [address]			[description]				and [name]								of [address]			[description]
Be it remembered that on 			          , a medical referee, appointed for the purposes of the Workers’ Compensation Act 1951, certified that A.B.,	of	, a 
worker under no legal disability [or a child of the age of		years], was suffering from	, a disease coming within the Workers Compensation Act 1951, section 9 of, and was thereby disabled from earning full wages at the work at which he or she was employed.
[or That on 				, A.B.		of		, a worker under no legal disability [or a child of the age of                            years] was, under the [give the short title of the Act in question] suspended from his or her usual employment on account of his or her having contracted		                 , a disease coming within the Workers Compensation Act 1951, section 9.
And that A.B.			alleged that the disease was due to the nature of his or her employment in				              [describe employment],			 of			, and that he or she was last employed in such employment within the 12 before the date of disablement or suspension by C.D.,			of			.
And that on 									, the following agreement was come to by and between the said			  and 								:
[or And that on 						, the following decision was given by a committee representative of the said		             and their workers, having power to settle matters under the Act in the case of			and their workers:]
[or And that on 						, the following award was made and given by me, the undersigned			     , being an arbitrator agreed on by			and		:]
[Here set out copy of agreement, decision, or award.]
If a medical referee has been appointed to report, add—
A copy of the report of E.F.,			, a medical referee appointed to report in this matter, is annexed.
[Add, if so, The medical referee			attended the arbitration on 						.
You are requested to record this memorandum, under the Workers Compensation Act 1951, schedule 4, clause 9.
Dated:
[To be signed in accordance with rule 36 (1), (2).]
Note	This form to be adapted to the circumstances of the case and the matter decided.
(iii)  Where death resulted from the injury.
To the Registrar of the Magistrates Court, Canberra.
In the matter of the Workers Compensation Act 1951,
and
In the matter of an Arbitration between [name]					of [address]			[description]		          Applicant,	and [name]								of [address]			[description]		          Respondents.
[Or, where the matter has been decided by agreement without arbitration],
In the matter of an agreement between [name]					of [address]			[description]				and [name]								of [address]			[description]
Be it remembered, that on							, personal injury was sustained by			late of			   , deceased, being injury arising out of and in the course of his or her employment, and that on 							,			   died as the result of such injury.
And that on 						, the following agreement was come to by and between			, the dependants of				          within the meaning of the Workers Compensation Act 1951, and				:
[or And that on					, the following decision was given by a committee representative of		             and their workers, having power to settle matters under the Workers Compensation Act 1951 in the case of			and their workers:]
[or And that on 				     , the following award was made and given by me, the undersigned			    , being an arbitrator agreed on by			the dependants of	              , within the meaning of the Workers Compensation Act 1951, and					:]
[Here set out copy of agreement, decision, or award.]
If a medical referee has been appointed to report, add—
A copy of the report of E.F.			, a medical referee appointed to report in this matter, is annexed.
[Add, if so, The medical referee			attended the arbitration on 							.
You are requested to record this memorandum, under the Workers Compensation Act 1951, schedule 4, clause 9.
Dated:
[To be signed in accordance with rule 36 (1), (2).]
Note	This form to be adapted to the circumstances of the case and the matter decided.
(iv)  Where death resulted from industrial disease.
To the Registrar of the Magistrates Court, Canberra.
In the matter of the Workers Compensation Act 1951,
and
In the matter of an arbitration between [name]					of [address]			[description]		          Applicant,	and [name]								of [address]			[description]		          Respondents.
[Or, where the matter has been decided by agreement without arbitration],
In the matter of an agreement between						of												and						of
Be it remembered, that on the			day of			                ,			        , a medical referee appointed for the purpose of the Workers Compensation Act 1951 certified that A.B.			of		  was suffering from			, a disease coming within that Act, section 9, and was thereby disabled from earning full wages at the work at which he or she was employed; and on 						A.B.		          died, his or her death being caused by the said disease;
[Or, That on 						A.B.			of			was, under the [give short title of the Act in question], suspended from his or her usual employment on account of his or her having contracted			     , a disease coming within the Workers Compensation Act 1951, section 9, and on 				A.B.			died, his or her death being caused by the said disease:]
[Or, That on 						A.B.			late of				died, his or her death being caused by			, a disease coming within the Workers Compensation Act 1951, section 9:
And that the dependants of A.B.			        alleged that the disease was due to the nature of the employment of the said A.B.		              in			[describe employment] and that he or she was last employed in such employment within 12 months before his or her disablement or suspension [or, if the worker died without having obtained a certificate of disablement, or was at the time of his or her death in receipt of a weekly payment on account of disablement, within 12 months before his or her death] by C.D.			of		              .]
And that on 					     , the following agreement was come to by and between			, the dependants of						, within the meaning of the Workers Compensation Act 1951, and 				,			 that is to say:		              [or And that on 						, the following decision was given by a committee representative of the said		             and their workers, having power to settle matters under the that Act in the case of 					and their workers:]
[or And that on				, the following award was made and given by me, the undersigned, being an arbitrator agreed on by				, the dependants of 				                     , within the meaning of the Workers Compensation Act 1951, and			                 .]
[Here set out copy of agreement, decision, or award.]

[If a medical referee has been appointed to report, add—
A copy of the report of E.F.			, a medical referee appointed to report in this matter, is annexed.]
[Add, if so, The medical referee			attended the arbitration on					.]
You are requested to record this memorandum, the Workers Compensation Act 1951, schedule 4, clause 9.
Dated:
[To be signed in accordance with rule 36 (1), (2).]
Note	This form to be adapted to the circumstances of the case and the matter decided.

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