Approved form AF2002-176

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 51
(see r 57 (9))
Certificate of medical referee
[Heading as in application.]
In accordance with the reference made to me by the Registrar of the Magistrates Court the Workers Compensation Rules 1938, rule 57, I have on 								, examined			of		        [name and address of worker], and I certify that the nature of his or her incapacity is as follows,			and is [or is not] likely to be of a permanent nature [or that the absence of the worker from Australia is [or is not] desirable for recuperative purposes].
Dated:
Medical referee.

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