DOSHI

REPUBLIC OF KENYA
DIRECTORATE OF OCCUPATIONAL SAFETY AND HEALTH SERVICES
NOTICE BY EMPLOYER OF AN OCCUPATIONAL ACCIDENTIDISEASE OF AN EMPLOYEE
PART!
1. Employer/Occupier Particulars'-
ii. Name of Employer/Occupier. , .
111. WIBA' registration No OS:HA' Registration No : , .
IV. Full Address P. O. Box Physical Location .
Y. E-Mail address Tel. .
vi. Nature of Work .
vn. Name and address of Insurance Company which has insured employee against accident

2. The Injured/sick employee-s particulars :-

i. Name .
11. Sex .
111. Age ,.
.iv. Occupation ', .
v. Full Address : : .
vi. E- Mail address '," Tel: .
vii, Identity Card No. *(Incase of fatal injury, Death Certificate No.) .
viii. Home District: : Division: : Location: , Sub-location .

3. Occupational Accident
1. Date of Accident , Time: Fatal!Nonfutal .
11.. Has the worker resumed 'working Yes/No '.".' Date of resumption .
111. Place where accident took place , .
iv. What is the iniured worker's Occupation .
v. What duties was the employee undertaking at the time ofthe accident? .
vi. Length of service with the present employer.. : .
vii. What work is the worker employed to undertake .
viii. Cause of Injury ...........................................................•.•................................................................
ix, Type ofIniury : .
X, Part of Body Injured ; .

4. Occupational Disease
Detail about the Occupational disease affecting the employee.
i. Date of diagnosis of the occupational disease .- , ,
ii. Name of medical practitioner who made the diagnosis -:-:,.. : .
111. Date the employer was notified ofthe disease by the employee or medical practitioners , .
IV. Describe the Cause ofthe occupational disease c .

5. Total Monthly earning at the date ofthe Accident/disease>

Salary/wage .. Sh .

Allowances paid regularly (including house, medical etc) .. Sh .

Overtime payment or/and other special remuneration tor work done whether by \yay
of bonus otherwise if of constant character and for work habi tually perforrned.. Sh.. " .

Total earning per month Sh .

Total earnings paid to the employee during the period of incapacity .. Sh .

Name of Employer or person notifying on behalf of Employe r . Signature .

Designation . ... Date .

 Duplicate and Triplicate: - To the medical practitioner attending or examining the injured/sick employee.
In the case of'an occupational accident/disease causing the death ofan employee, Part 1 should be completed in duplicate and
then dispatched immediately as under:
Original and duplicate: - To the Occupational Health and Safety Officer in charge of the District in which the accident
occurred. ,.
PART 11
MEDICAL REPORT
(for use by the medical practitioner the
Name of employee .
Date admitted to hospital. Discharged .
In-patient No \. .' .
Attendance as out-patient from to .
. N 1.
O ut -panent 0.. : .........................•.....................................................................................................

Occupational disease .
Is there permanent incapacity? "Yes/Nc .
If yes please give: .
a) Details and nature of permanent incapacity ;: '.:' ; -.. , : .
•••• __••••••••••••••••••••••••••••••••••••••••••••••••••••••.•••.••••••••••••••.••••••••••••.••••••••••••••• 0 ••• · ••••••••••••••••••••••••••••••••••

. . .
...........................................................................................................................................
~ .

......... - - - .
b) Percentage of permanent incapacity to be indicated in both words and figures, ,.'-~.-:-: '" .
...................................................................................
- - -

- - .
•••.•• '_"_0" .- -••••••.•••••••••• -
00 ••••••••••••••
_.. -'
:~._~.! -.._ _ _.'_'.-
- .. - ~ - _ .
. .: ..~~..;.:..:.. :: :.. . per cent. _
Temporary incapacity :-( Likely duration of absence from work, from date of acquiring disease/or diagnosis etc.) : .
.. weeksl months"
Is a further examination required before final assessment of permanent incapacity can be given". .Ifyes ; . .
a) which ones .- . , .
.••••••••••••••.•••••••••••••••••••••••••••••• •••••••••• ••••• •••••••••••• ;~ •••••••••••••••••••••••••••••••••••••••••••••••• '!'. •••••••••••••••••••••••••••••••••••••••••••••••••••••••••• :- •.••• : ••••••••••••••••

b) when? : .
Name of medical Practitioner. ', .
Signature Date .
Name of Hospital/Clinic/Private Practice ................•...................................... ; : : ..................................•........

Note:-It is requested that this part be completed by the medical practitioner in duplicate.fhe form then being dispatched as under:
1. One copy to the employer. _ -
2. One copy to the Occupational Health and Safety Officer in charge. of the district i~ which the accident occurred

PART 111
(For use by Occupational Health and Safety Officer) .
Compensation *is I i-snot being claimed on behalf of the employee/dependants of the deceased employee.
District and Accident Register No ~ .

Station ~ '" . Date ; .

Occupational Health and Safety Officer

GPK(L)

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