1987 Ed.]
Employees' Compensation Regulations
[CAP.282
FORM 2A
表格二甲
EMPLOYEES' COMPENSATION ORDINANCE, CAP. 282 僱員賠償條例(香港法例第二八二章)
SECTION 15
第十五条
[reg. 4.]
(規例第四條)
NOTICE BY EMPLOYER OF THE DEATH OR INCAPACITY OF AN EMPLOYEE DUE TO OCCUPATIONAL DISEASE
由僱主呈報有關僱員因職業病而致死亡或喪失工作能力之通知書
(To be completed and returned in DUPLICATE to the Labour Department WITHIN 7 DAYS of the employee's incapacity or death 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,並於僱員喪失工作能力或死亡後之七日內,或在勞工處處長指定之期間內呈交勞工處,僱主如不遵時呈報,可能會被檢控。)
To the Commissioner for Labour, Hong Kong.
Name of employee (Surname first)
僱員姓名(先寫姓)
Address of employee
Occupation
Sex
Age
性别
年齡
An apprentice? | Duration of employment
Yes/No*
Identity Card Number
身份證號
Residential Telephone Number
住所電話
[Subsidiary]
L.N. 40/87.
Disease suffering from 所患之職業病
From
to
Date of onset of the occupational disease
開始患職業病日期
Types of work attributed to the occupational disease-
引起職業病之工作類別
Name of hospital or clinic where employee received treatment
僱員就診之醫院或診所名稱
The occupational disease resulted in death/partial/total* incapacity of a permanent/temporary* nature
該職業病引致僱員死亡/暫時/永久*喪失全部/部分*工作能力*
Name of employing company/person
Address of employing company/person
Telephone Number
僱用公司名稱/僱主姓名 僱用公司/僱主之地址
電話號碼
Trade
Name and address of principal contractor if employer is a sub-contractor
如僱主為轉包承判商,請列明總承判商之名稱及地址
Telephone Number of principal contractor
總承判商之電話號碼
If death is resulted, state: Police not notified/notified* at
如意外引致死亡,請說明:未有報警/已通知*
Name of next-of-kin
Address of next-of-kin
親屬姓名 親屬地址
Relationship with employee
與僱員關係
Station
Telephone Number
電話
Paid rest day?
Yes/No*
休息日是否有薪?
是/否
Average number of days per week/month* worked
每週/月*平均工作之日數
!
1987 Ed.]
Employees' Compensation Regulations
[CAP.282
FORM 2A
表格二甲
EMPLOYEES' COMPENSATION ORDINANCE, CAP. 282 儷員賠償條例(香港法例第二八二章)
SECTION 15
第十五条
[reg. 4.]
(規例第四條)
NOTICE BY EMPLOYER OF THE DEATH OR INCAPACITY OF AN EMPLOYEE DUE TO OCCUPATIONAL DISEASE
由主呈報有關體員因職業病而致死亡或喪失工作能力之通知書
(To be completed and returned in DUPLICATE to the Labour Department WITHIN 7 DAYS of the employee's
incapacity or death 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,並於僱員喪失工作能力或死亡後之七日內,或在勞工處處長指定之期间内呈交勞工處,僱主如不做時記報,可能會被 檢控口)
To the Commissioner for Labour, Hong Kong.
Name of employee (Surname first)
僱員姓名(諺先纖姓)
Address of employee
Occupation
Sex
Age
性别
年齡
An apprentice? | Duration of employment ECAN
Identity Card Number
身份證號
Residential Telephone
Number 住所電話
A7
[Subsidiary]
L.N, 40/87.
Yes/No*
Disease suffering from 所患之海症
From
to
Date of onset of the occupational disease
開始患濊糪病日期
Types of work attributed to the occupational disease-
引起職業病之工作類別
Name of hospital or clinic where employee. received treatment
僱員就診之顆院或診所名稱
The occupational disease resulted in death/partial/total" incapacity of a permanent/temporary" nature 該職業病引致絯僱員死亡/暫時/永久蹇先全都/海郡工作能力*
Name of employing
Address of employing company/
Telephone
company/person
person
Number
僱用公司名稱/髴主姓名 儷限公司/僱主之地址
電話號碼
Trade
Name and address of principal contractor if employer is a sub-contractor 如最主咸轉包承判商,請列明總承判商之名稱紥地址
Telephone Number of principal
contractor
承判商之電話號碼
If death is resulted, state: Police not notified/notified" at
如意外引致藎燒死亡,請說明:未有報警/已通知...
Name of next-of-kin
Address of next-of-kin
遊䍲地址
Average number of days per week/month* worked 每週/月 平約工作之日數
Relationship with employee
Station
Telephone Number 電話
Paid rest day?
Yes/No*
休息日是否有薪?
是/否
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