1987 Ed.]
Employees' Compensation Regulations
[CAP. 282
AS
[Subsidiary]
" FORM 2
[reg. 4.]
【規例第四條】
EMPLOYEES' COMPENSATION ORDINANCE, CAP. 282 僱員賠償條例(香港法例第二八二章)
SECTION 15
第十五條
NOTICE BY EMPLOYER OF THE DEATH OF AN EMPLOYEE OR OF AN ACCIDENT
TO AN EMPLOYEE RESULTING IN DEATH OR INCAPACITY
僱主報告僱員死亡或僱員因意外而致死亡或受傷之通知書
(To be completed and returned in DUPLICATE to the Labour Department WITHIN 7 DAYS of the accident or
within such period of time as required by the Commissioner for Labour. An employer who fails to do so may be
prosecuted.)
(請填寫一式兩份,並於意外發生後之七日內,或在勞工處處長指定之期間內交勞工處,僱主如不依時呈報,可能會被檢控。)
To the Commissioner for Labour, Hong Kong.
Name of injured employee (Surname first)
受傷僱員姓名(先寫姓)
Sex 性別
Age
Identity Card Number
年齡
身份證號碼
Address of injured employee
受傷僱員地址
Occupation
An apprentice? 是否學徒?
Yes/No*
Date of Accident] Residential Telephone
意外發生日期 Number 住所電話
Did the accident occur in the course of work? 意外是否在工作時發生?
Result of accident: Injury/Death*
意外引致:受傷/死亡*
Nature of injury-amputation*/fracture*/contusion*/laceration*/burn*/others* (please specify)
受傷性質-截肢*/骨折*/挫傷*/割傷*/燒傷*/其他* (請註明)
Part of body injured--hand*/leg*/head* others* (please specify) 受傷之部位-
Yes/No*
Name of hospital or clinic where injured
employee received treatment
受傷僱員接受治療之醫院或診所名稱
Describe how the accident happened
請詳細說明意外如何發生
Address of the place of accident
意外發生地點之地址
Please
state whether the place of
accident is an industrial type building,
site, godown, on board a ship, etc.
請註明意外發生地點是否工業樓宇、地盤、倉庫、船上等。
If accident is due to machinery, state:
若意外由機器引起,列出:
Type of machine
機器類別
Was the machinery power-driven?
Was the machinery in motion? 機器是否開動?
Part of machine causing injury
Name of employing
Address of employing company/
company/person
person
僱用公司名稱/僱主姓名
僱用公司/僱主地址
Telephone
Number
Trade
行業
電話號碼
Yes/No*
是/否
Yes/No*
Name and address of principal contractor if employer is a sub-contractor 如僱主是分包承判商,請列明總承判商之名稱及地址
If accident resulted in death, state: Police not notified/notified* at 如意外引致死亡,請說明:未有報警/已通知...............
Telephone Number of principal contractor
總承判商之電話號碼
Station
L.N.40/87.
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