Approved form AF2002-186

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 62
(see r 75)
Order of reference under the Act, schedule 1, paragraph 11 
[Heading as in application.]
On the application of A.B.			of			             and C.D.			, of		    [a copy of which is annexed], I appoint 			, of			, a medical referee appointed for the Workers Compensation Act 1951, to examine [name of worker], and to give his or her certificate as to the condition of the worker			             and his or her fitness for employment, specifying, where necessary, the kind of employment for which he or she is fit [or his or her certificate whether] [or to what extent] the incapacity of	the worker			   is due to the injury] [or his or her certificate as to the condition of the worker			 and his or her fitness for employment, specifying, where necessary, the kind of employment for which he or she is fit, and as to whether [or to what extent] the incapacity of the worker 				is due to the injury].
Copies of the reports of the medical practitioners by whom the worker	 has been examined are annexed.
The worker			, who is now at			  , has been directed to submit himself or herself for examination by the referee.
I am satisfied that the worker			   is in a fit condition to travel for the purpose of being examined, and he or she has been directed to attend on the referee for examination at such time and place as may be fixed by the referee.
[or, The worker			     does not appear to be in a fit condition to travel for the purpose of being examined.]
The referee is requested to forward his or her certificate by registered post to the Registrar at the Office of the Magistrates Court situate at Canberra on or before 					.
Dated:
Registrar of the Magistrates Court.

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