PNEUMOCONIOSIS ACT: SUBSIDIARY LEGISLATION

Where an employer is required by the Act to present an employed miner to the Bureau for a prescribed examination and where the Chairman of the Board requires any miner to attend at his office for interview in connection with compensation, the Bureau shall provide transport from the place of employment to the Bureau and return for every such examination or interview.

[As amended by No. 36 of 1956]

4. Charges for transport of persons other than employed miners

(1) An employer shall pay to the Bureau the charges set out below, in respect of every person, other than an employed miner, who is presented by such employer to the Bureau for a prescribed examination and who travels to and from, or to or from, the Bureau for such purpose in transport provided and paid for by the Bureau.

CHARGES

		Fee units
(a)

Mufulira Copper Mine . . . . . . . .

(b)

Roan Antelope Copper Mine . . . . . .

(c)

Nchanga Copper Mine . . . . . .

(d)

Bancroft Copper Mine . . . . . .

(e)

Chibuluma Copper Mine . . . . . .

(f)

Chambishi Copper Mine . . . . . .

(2) All moneys received by the Bureau by virtue of the provisions of this regulation shall be paid into the general revenues of the Republic.

[As amended by 36 of 1956; 330 of 1962; 285 of 1963; 124 of 1965 and Act 13 of 1994.]

5. Employed miner to be paid basic wages when absent for prescribed examination

Where an employer is required by the Act to present an employed miner to the Bureau for a prescribed examination and so presents such miner and where the Chairman of the Board has required any miner to attend at his office for interview in connection with compensation and such miner has so attended, the employer shall pay to such miner the basic wages he would normally have earned during the period he is necessarily absent from work for the purpose of undergoing such examination or attending for such interview.

[As amended by 36 of 1956.]

6. Prescribed fee

The prescribed fee payable under sub-section (6) of section 39 of the Act shall be 63 fee units.

[Am by GN 330 of 1962 and Act 13 of 1994.]

PNEUMOCONIOSIS (FORMS) REGULATIONS

[Section 96]

Arrangement of Regulations

Regulation

1. Title

2. Prescribed forms

SCHEDULE

GN 208 of 1957,

GN 331 of 1962,

GN 284 of 1963,

GN 497 of 1964,

SI 124 of 1965,

SI 229 of 1965.

[Regulations by the Minister]

1. Title

These Regulations may be cited as the Pneumoconiosis (Forms) Regulations.

2. Prescribed forms

The forms set out in the Schedule are hereby prescribed for use in the cases to which they respectively refer.

SCHEDULE

FORM 1

R.Z. BUREAU NO.

M.B........

PRESCRIBED FORMS

MINE REGISTRATION NO

..............

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

APPLICATION FOR MEDICAL EXAMINATION OF THE NATURE INDICATED BELOW

1. INITIAL (Section 39).

2. INITIAL failing which SPECIAL (Section 39 (3) (c) and 39 (4) and proviso to 39 (5)).

3. INITIAL failing which INITIAL (RESTRICTED) to employment as..................................................... (Section 39 (3) (b) and proviso 39 (5)).

4. BENEFITS (Section48). Not appli- cable to men in employment as miners previously examined by the Bureau, Form 2 must be used instead of this Form.

Name in full (BLOCK CAPITALS) ..........Date of examination .........................................................

Age ...Mine ............................... *Mine No ..............................*National Registration No ........................................

*Place of birth ..................................................... Address for letters ......................

.........................................................

*Chief ..................................................... *Village ..........................................................................................................

*District .................................................. *Country ........................................................................................................

* Complete as required

Have you been examined and given a number by any of the Bureaux named?

If so, state the number.

R.Z. Bureau Number .....................................................

S.A. Bureau Number .....................................................

S.R. Bureau Number .....................................................MINING SERVICE

Fill up the table below as accurately as possible, stating the years (e.g. 1926-32 or 1943-44 and 1946) during which you have worked in each place named and stating the number of months worked in each of the occupations named.

NOTE.-When this form is used for the re-examination of any man who has been previously examined by the Bureau, it is sufficient to write in the space for mining service "Service since last examined" followed by the particulars of that service only.

*Country, Name and Nature of Mine	Dates of Service	Surface Scheduled Service in Months	Underground Service in Months	Total
		Concentrator Including Crushers, Screening and Belt Conveyors	Other Including Sample Crushing, Change House, Tailing Dump, Rock Drill Sharpening, Coal Plant	Production Including Drilling, Blasting, Lashing Rock Removal, Ore Transport	Other Including Pumps, Sanitation, Pipe Fitting, Survey, Tracks, Sampling, Timbering, etc.

			Grand Total. . . . . .

*Country to be shown as R.Z., Zim., S.A. or "Elsewhere". Nature of mine to be shown as "Gold", "Asbestos", "Coal" or "Other". Country and nature may be omitted for R.Z. Copper Mines. Put a line after the record of service for any mine.

I declare that the above statements are true to the best of my knowledge and belief.

Signature or thumb-print of person examined: Signature of Witness: .................

.......................................................................... .....................................

Place of examination if not the R.Z. Bureau:

...................

FORM 2

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

R.Z. BUREAU NO.

M.B. ..........

MINE REGISTRATION NO.

.............

APPLICATION FOR MEDICAL EXAMINATION OF THE NATURE INDICATED BELOW

1. PERIODICAL (SECTIONS 40, 41, 42).	2. PERIODICAL Re-stricted (SECTION 43 (1) (b)).	3. Discharge (SECTION 44).	4. Suspect (SECTION 47).	5. Additional (SECTION 49). Applicable only to men in employment as miners.	6. Benefits (SECTION 48). Not applicable to men in employment as miners and if the man has not been previously examined by the Bureau, Form 1 must be used instead of this Form.
Engagement Employee	Engagement Employee

Name in full (BLOCK CAPITALS) .........................Date of examination .................................

Age ................ Mine ............................... *Mine No. .....*National Registration No .......................................

*Place of birth ..................................................*Address for letters or tribal particulars ...............

................................................

*Complete as required.

Have you been given a number by either of the Bureaux named since last examined by or for the R.Z. Bureau?

If so, state number.

{S.A. Bureau No. ................................................................

S.A. Bureau No. ................................................................

What occupation other than mining have you been engaged in since your last examination by the R.Z. Bureau? ............................

MINING SERVICE SINCE LAST BUREAU EXAMINATION

Country, Name and Nature of Mine	Dates of Service	Surface Scheduled Service in Months	Underground Service in Months
Concentrator Including Crushers, Screening and Belt Conveyors	Other Including Sample Crushing, Change House, Tailing Dump, Rock Drill Sharpening, Coal Plant	Production Including Drilling, Blasting, Lashing Rock Removal, Ore Transport	Other Including Pumps, Sanitation, Pipe Fitting, Survey, Tracks, Sampling, Timbering, etc.

Cumulative Absence from work of more than 14 days (Leave, Hospital, etc.) No. of Days ............

Right thumb-print

I declare the above statement to be true to the best of my knowledge and belief.
Signature or thumb-print of person examined:
.....................
Signature of Witness............
Place of examination if not Republic of Zambia
.....................

(This entry to be put in by a member of the Bureau staff.) Apparent total mining service to date:
.................months
R.Z. .................
Elsewhere ..............

FORM 3

(FACE)

BUREAU NO.

M.B.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

INITIAL CERTIFICATE

Full name ..........................

Address ...........................

This is to certify that the person named above underwent on ................................... an initial examination as prescribed by section 39 of the Pneumoconiosis Act and was found to satisfy the requirements for the issue to him of this certificate.

{mprestriction ids="2,3,5"}

The validity of this certificate expires on ..................................

after which date the certificate will be of no effect.

.............

Secretary of the Bureau

Kitwe, ...............

...............

Signature or right thumb-print of

person named above

INITIAL (RESTRICTED) CERTIFICATE

(BACK)

If the word "Restricted" is stamped upon the face of this certificate, then this certificate is valid only for the occupations and only at the mine named below.

OCCUPATIONS:

................................................

MINE:

................................................

FORM 4

(FACE)

BUREAU NO.

M.B........

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

PERIODICAL CERTIFICATE

Full name ...........................................

Address ...............................................

This is to certify that the person named above underwent on ................................... a periodical examination as prescribed by section 40 of the Pneumoconiosis Act and was found to satisfy the requirements for the issue to him of this certificate.

The validity of this certificate expires on...................................

after which date the certificate will be of no effect.

Tuberculosis is absent. Pneumoconiosis is absent/pneumoconiosis is present in the first/second stage.

.............

Secretary of the Bureau

Kitwe, ...........

..................

Signature or right thumb-print of

person named above

PERIODICAL (RESTRICTED) CERTIFICATE

(BACK)

If the word "Restricted" is stamped upon the face of this certificate, then this certificate is valid only for the occupations and only at the mine named below.

OCCUPATIONS:

................................................

MINE:

................................................

FORM 5

(FACE)

BUREAU NO.

M.B.........

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

SPECIAL CERTIFICATE

(See important note on back)

Full name ............................................

Address ............................................

The validity of this certificate expires on .................................after which date the certificate will be of no effect.

.............

Secretary of the Bureau

Kitwe, ...................

.................

Signature or right thumb-print of person named above

IMPORTANT NOTE

(BACK)

This certificate is issued under the authority of section 39 (3) (c) and (5) of the Pneumoconiosis Act. It is not lawful for the person in respect of whom it is issued to work as a "miner" or for an employer to employ him as a "miner" for an aggregate of more than 100 hours in any period of thirty days.

FORM 6 B.1

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

..............

Date ........

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. Box 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Section 39 (3) (a))

Name of person reported on ....................................

Date of examination .......................................

With reference to the examination on the above date, I am directed to report as follows:

(1) A Republic of Zambia INITIAL CERTIFICATE valid to ....................... has been sent to the Mine Secretary of ...............................Mine. is enclosed herewith.

*(2) The original of this report has been sent to the Mine Secretary of .....................Mine.

..................

Secretary of the Bureau

*To examine if not presented for examination by employer or prospective employer with copy to Mine Secretary if previously employed as a miner in scheduled mines.

FORM 7 B.2

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. Box 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Initial: Section 39 (3) (b))

Name of person reported on ...................................

Date of examination .......................................

With reference to the examination on the above date, I am directed to report as follows:

(1) A Republic of Zambia INITIAL (RESTRICTED) CERTIFICATE valid to

.....................................has been sent to the Mine Secretary of ......................................Mine.

(2) The validity of the above-mentioned certificate is restricted to the occupations of ............................................ at ............................................ Mine.

(3) Tuberculosis is absent.

Pneumoconiosis is absent/present in the first/second stage.

(4) The date of this certification is ...................................

(5) Previous certifications if any:

Pneumoconiosis in the first stage .................................

Pneumoconiosis in the second stage ................................

(6) A copy of this report has been sent to:

*Examinee.

*The Secretary, Zambia Pneumoconiosis Compensation Board.

(7) The original of this report has been sent to the Mine Secretary of ....................

Mine.

.................

Secretary of the Bureau

*These lines are for use only when the presence of pneumoconiosis is certified: delete in other cases.

FORM 8 B.3

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. Box 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Initial: Section 39 (3) (c))

Name of person reported on ...................................

Date of examination .......................................

With reference to the examination on the above date, I am directed to report as follows:

(1) A Republic of Zambia SPECIAL CERTIFICATE valid to ..................... has been sent to the Mine Secretary of ............................Mine.

(2) Pneumoconiosis is absent.

Pneumoconiosis is present in the first/second stage. Tuberculosis is absent.

(3) The certificate named constitutes an authority for the person in respect of whom it is issued to work or to be employed as a "miner" provided that his work in that capacity does not exceed in aggregate 100 hours in any month. (Section 39 (3) (c) and (4) of the Pneumoconiosis Act.)

(4) Previous certifications if any:

Pneumoconiosis in the first stage .................................

Pneumoconiosis in the second stage ................................

(5) A copy of this report has been sent to:

*The Examinee.

*The Secretary, Zambia Pneumoconiosis Compensation Board.

(6) The original of this report has been sent to the Mine Secretary of ...................

Mine.

.............

Secretary of the Bureau

*These lines are for use only when the presence of pneumoconiosis is certified: delete in other cases.

FORM 9 B.4

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. Box 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Initial: Section 39 (3) (d))

Name of person reported on ...................................

Date of examination .......................................

With reference to the examination on the above date, I am directed to report as follows:

(1) NO CERTIFICATE can be issued since the person named above is not up to the physical standard required by law. He is at liberty, however, to apply for re-examination after months from the date of this report.

(2) Pneumoconiosis is absent; tuberculosis is absent.

*(3) The original of this report has been sent to the Mine Secretary of ..................

Mine.

.................

Secretary of the Bureau

*To examine if not presented for examination by employer or prospective employer with copy to Mine Secretary if previously employed as a miner in scheduled mines.

FORM 10 B.5

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONOSIS MEDICAL AND RESEARCH BUREAU

P.O. Box 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Initial: Section 39 (3) (e))

Name of person reported on ....................................

Date of examination .......................................

With reference to the examination on the above date, I am directed to report as follows:

(1) NO CERTIFICATE can be issued since the person named above is found by the Bureau to be not fit for work as a miner in any circumstances. He is therefore not eligible to be examined again by this Bureau for a certificate of fitness.

(2) Pneumoconiosis is absent/present in the ........................stage.

Tuberculosis is absent/present.

(3) A copy of this report has been sent to:

*The Secretary, Zambia Pneumoconiosis Compensation Board.

*The Examinee

**(4) The original of this report has been sent to the Mine Secretary of ..................

Mine.

.................

Secretary of the Bureau

*These lines are for use only when the presence of pneumoconiosis and/or tuberculosis is certified; delete in other cases.

**To examine if not presented for examination by employer or prospective employer with copy to Mine Secretary if previously employed as a miner in scheduled mines.

FORM 11 B.6

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. Box 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Periodical: Section 43)

Name of person reported on ....................................

Date of examination .......................................

With reference to the examination on the above date, I am directed to report as follows:

(1) A Republic of Zambia PERIODICAL CERTIFICATE, valid to ..................

has been sent to the Mine Secretary of ...........................Mine. is enclosed herewith.

(2) Pneumoconiosis and tuberculosis are both absent.

*(3) The original of this report has been sent to the Mine Secretary of .................

Mine.

.................

Secretary of the Bureau

NOTE-If the word "Restricted" is stamped on the face of this report, it implies that the certificate referred to above was issued under special provisions of the pneumoconiosis law and that such certificate is valid only for the occupations of:

.............................................

..............................................

at the following mine:

.............................................

..............................................

.............................................

*To examine if not presented for examination by employer or prospective employer with copy to Mine Secretary.

FORM 12 B.7

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. Box 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Periodical: Section 43)

Name of person reported on ......................................

Date of examination ...................................................

With reference to the examination on the above date, I am directed to report as follows:

(1) A Republic of Zambia PERIODICAL CERTIFICATE valid to .......................

has been sent to the Mine Secretary of ................................Mine

is enclosed herewith.

(2) Pneumoconiosis is present in the first stage. Tuberculosis is absent.

(3) The date of this certification is .................................

_________________________

(4) Previous certifications if any:

Pneumoconiosis in the first stage ....................................

(5) A copy of this report has been sent to:

The Secretary, Zambia Pneumoconiosis Compensation Board.

*(6) The original of this report has been sent to the Mine Secretary of ................Mine.

..................

Secretary of the Bureau

NOTE.-If the word "Restricted" is stamped on the face of this report, it implies that the certificate referred to above was issued under section 43 (1) (b) of the Pneumoconiosis Act and that such certificate is valid only for the occupation of:

.............................................

at the following mine:

.............................................

*To examinee if not presented for examination by employer or prospective employer with copy to Mine Secretary.

FORM 13 B.8

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU P.O. Box 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Periodical: Section 43)

Name of person reported on ....................................

Date of examination ..........................................

With reference to the examination on the above date, I am directed to report as follows:

(1) A Republic of Zambia PERIODICAL CERTIFICATE valid to ......................

has been sent to the Mine Secretary of ...............................Mine. is enclosed herewith.

(2) Pneumoconiosis is present in the second stage. Tuberculosis is absent.

(3) The date of this certification is .................................

(4) Previous certifications if any:

Pneumoconiosis in the first stage .....................................

Pneumoconiosis in the second stage ..................................

(5) A copy of this report has been sent to: The Examinee.

The Secretary, Zambia Pneumoconiosis Compensation Board.

*(6) The original of this report has been sent to the Mine Secretary of ..................

Mine.

.................

Secretary of the Bureau

.............................................at the following mine: .......................................

*To examinee if not presented for examination by employer or prospective employer with copy to Mine Secretary.

FORM 14 B.9

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. Box 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Periodical: Section 43)

Name of person reported on ......................................

Date of examination .........................................

With reference to the examination on the above date, I am directed to report as follows:

(1) For the reason stated in paragraph (2) NO CERTIFICATE can be issued.

(2) Pneumoconiosis is present in the third stage without tuberculosis.

Tuberculosis is present without pneumoconiosis. Tuberculosis and pneumoconiosis are both present.

(3) The date of this certification is ................................

(4) This certification immediately and finally cancels any existing certificate in respect of the person named above authorising him to work or to be employed as a "miner" in Zambia and the law requires that he forthwith cease to be so employed.

(5) Previous certifications if any:

Pneumoconiosis in the first stage .....................................

Pneumoconiosis in the second stage ...................................

(6) A copy of this report has been sent to:

The Secretary, Zambia Pneumoconiosis Compensation Board. The Examinee.

*(7) The original of this report has been sent to the Mine Secretary of ..................Mine.

................

Secretary of the Bureau

*To examine if not presented for examination by employer or prospective employer with copy to Mine Secretary.

FORM 15 B.9a

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. BOX 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Periodical: Section 43 (1) (c))

Name of person reported on .......................................

Date of examination .........................................

With reference to the examination on the above date, I am directed to report as follows:

(1) Pneumoconiosis is absent.

Pneumoconiosis is present in the first/second stage.

Tuberculosis is absent.

(2) Despite the absence of tuberculosis and of pneumoconiosis in the third stage NO CERTIFICATE can be issued for the reason stated in paragraph (3).

(3) The Bureau is of the opinion that the fitness for work as a miner of the person reported on has been seriously impaired by old age/disease. (Section 43 (1) (c) of the Pneumoconiosis Act.)

(4) Previous certifications if any: Pneumoconiosis in the first stage Pneumoconiosis in the second stage

(5) A copy of this report has been sent to:

*The Secretary, Zambia Pneumoconiosis Compensation Board.

*The Examinee.

**(6) The original of this report has been sent to the Mine Secretary of .................. Mine.

.............

Secretary of the Bureau

*These lines are for use only when pneumoconiosis is certified to be present.

**To examinee if not presented for examination by employer or prospective employer with copy to Mine Secretary.

FORM 16 B.10

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. BOX 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Benefits: Section 48)

Name of person reported on .......................................

Date of examination ..........................................

With reference to the examination on the above date, I am directed to report as follows:

(1) Pneumoconiosis is absent.

Tuberculosis is absent.

(2) Unless specially directed by the Director of the Bureau to present himself at the Bureau for re-examination at some earlier date, the person named above is not eligible to be re- examined by the Bureau sooner than one year from the date of the examination now reported on. (Section 48 (d) of the Pneumoconiosis Act.)

*(3) The original of this report has been sent to the Mine Secretary of .................... Mine.

.............

Secretary of the Bureau

*To examinee if not presented for examination by employer or prospective employer with copy to Mine Secretary.

FORM 17 B.11

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. BOX 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Benefits: Section 48)

Name of person reported on .......................................

Date of examination ..........................................

With reference to the examination on the above date, I am directed to report as follows:

(1) Pneumoconiosis is present in the ...............................stage.

Tuberculosis is absent.

(2) The date of this certification is ...................................

(3) Previous certifications if any:

Pneumoconiosis in the first stage .....................................

Pneumoconiosis in the second stage ...................................

Pneumoconiosis in the third stage ....................................

(4) Unless directed by the Director of the Medical Bureau to present himself for re- examination at some earlier date, the person named above is not eligible to be re-examined at the Bureau sooner than one year from the date of the examination now reported on. (Section 48 (d) of the Pneumoconiosis Act.)

(5) A copy of this report has been sent to:

The Secretary, Zambia Pneumoconiosis Compensation Board. The Examinee.

*(6) The original of this report has been sent to the Mine Secretary of .................... Mine.

.............

Secretary of the Bureau

*To examinee if not presented for examination by employer or prospective employer with copy to Mine Secretary.

FORM 18 B.12

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. BOX 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Benefits: Section 48)

Name of person reported on .......................................

Date of examination ...................................................

With reference to the examination on the above date, I am directed to report as follows:

(1) Tuberculosis is present.

Pneumoconiosis is absent.

(2) The date of this certification is ..................................

(3) Previous certification if any:

Tuberculosis without pneumoconiosis ................................

(5) A copy of this report has been sent to:

The Secretary, Zambia Pneumoconiosis Compensation Board. The Examinee.

*(6) The original of this report has been sent to the Mine Secretary of ..................... Mine.

.............

Secretary of the Bureau

*To examinee if not presented for examination by employer or prospective employer with copy to Mine Secretary.

FORM 19 B.13

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. BOX 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Benefits: Section 48)

Name of person reported on .......................................

Date of examination ...................................................

With reference to the examination on the above date, I am directed to report as follows:

(1) Pneumoconiosis is present.

Tuberculosis is present.

(2) The date of this certification is ................................

(3) Previous certifications if any:

Pneumoconiosis in the first stage .....................................

Pneumoconiosis in the second stage ...................................

Pneumoconiosis in the third stage .......................................

Pneumoconiosis with tuberculosis ......................................

Tuberculosis without pneumoconiosis ...................................

(5) A copy of this report has been sent to:

The Secretary, Zambia Pneumoconiosis Compensation Board. The Examinee.

*(6) The original of this report has been sent to the Mine Secretary of .................. Mine.

.............

Secretary of the Bureau

*To examinee if not presented for examination by employer or prospective employer with copy to Mine Secretary.

FORM 20 B.14

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. BOX 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Discharge: Section 44; Suspect: Section 47; or Additional: Section 49)

Name of person reported on .......................................

Date of examination ...................................................

With reference to the examination on the above date, I am directed to report as follows:

(1) Pneumoconiosis is absent.

Tuberculosis is absent.

(2) The original of this report has been sent to the Mine Secretary of .................... Mine.

.............

Secretary of the Bureau

*To examinee if not presented for examination by employer or prospective employer with copy to Mine Secretary.

FORM 21 B.15

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. BOX 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Discharge: Section 44; Suspect: Section 47; or Additional: Section 49)

Name of person reported on .......................................

Date of examination ...................................................

With reference to the examination on the above date, I am directed to report as follows:

(1) Pneumoconiosis is present in the first/second stage.

Tuberculosis is absent.

(2) The date of this certification is ..................................

(3) Previous certifications if any:

Pneumoconiosis in the first stage .....................................

Pneumoconiosis in the second stage ......................................

(4) A copy of this report has been sent to:

The Secretary, Zambia Pneumoconiosis Compensation Board.

The Examinee.

*(5) The original of this report has been sent to the Mine Secretary of .................. Mine.

.............

Secretary of the Bureau

*To examinee if not presented for examination by employer or prospective employer with copy to Mine Secretary.

FORM 22 B.16

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. BOX 205, KITWE

REPORT ON MEDICAL EXAMINATION

(Discharge: Section 44; Suspect: Section 47; or Additional: Section 49)

Name of person reported on .......................................

Date of examination ...................................................

With reference to the examination on the above date, I am directed to report as follows:

(1) Pneumoconiosis is present in the third stage without tuberculosis.

Tuberculosis is present without pneumoconiosis.

Tuberculosis and pneumoconiosis are both present.

(2) The date of this certification is ..................................

(3) This certification immediately and finally cancels the validity of any certificate of fitness in respect of the person named above authorising him to work or to be employed as a "miner" in Zambia and the law requires that he forthwith cease to be so employed.

(4) Previous certifications if any:

Pneumoconiosis in the first stage .....................................

Pneumoconiosis in the second stage ...................................

(5) A copy of this report has been sent to:

The Secretary, Zambia Pneumoconiosis Compensation Board. The Examinee.

*(6) The original of this report has been sent to the Mine Secretary of .................... Mine.

.............

Secretary of the Bureau

*To examinee if not presented for examination by employer or prospective employer with copy to Mine Secretary.

FORM 23 B.17

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. BOX 205, KITWE

REPORT ON MEDICAL EXAMINATION

[Sections 56 and 57]

Name of deceased person ........................................

Date of examination ...................................................

With reference to the post-mortem examination performed on the above date, I am directed to report as follows:

(1) Pneumoconiosis was found to be absent/present in the..................... stage.

Tuberculosis was found to be absent/present. Death was due to pneumoconiosis.

Death was not due to pneumoconiosis but pneumoconiosis was a contributory or predisposing factor.

Death was not due to pneumoconiosis and pneumoconiosis was neither a contributory nor a predisposing factor.

The date of this certification is .......................... i.e., the date of the post-mortem examination.

(2) In the case of the deceased person now reported on, certification of the presence of compensable disease during life was made as follows:

Pneumoconiosis in the first stage on ......................................

Pneumoconiosis in the second stage on ....................................

Pneumoconiosis in the third stage on .....................................

Pneumoconiosis with tuberculosis on ....................................

Tuberculosis without pneumoconiosis on .................................

(3) A copy of this report has been sent to:

*The Secretary, Zambia Pneumoconiosis Compensation Board.

The next of kin.

**(4) ................The original of this report has been sent to the Mine Secretary of ..............................................

Mine.

.............

Secretary of the Bureau

*Delete this line if no compensable disease was found.

**To next of kin if examination not arranged by employer with copy to Mine Secretary.

FORM 24 B.B

CONFIDENTIAL

BUREAU NO.

M.B. .........

MINE REGISTRATION NO.

.............

Date.......

REPUBLIC OF ZAMBIA

PNEUMOCONIOSIS MEDICAL AND RESEARCH BUREAU

P.O. BOX 205, KITWE

REPORT ON MEDICAL EXAMINATION

Name of person reported on .......................................

Date of examination ...................................................

With reference to the examination on the above date, I am directed to report as follows:

(1) The examination referred to above was inconclusive.

(2) Further examination is required as follows:

Clinical examination by the Bureau on date to be arranged.

X-ray examination by the Bureau on date to be arranged.

Examination of ..................specimens of sputum expectorated on successive days. Observation in hospital for ................ days.

(3) (For use when the person examined is employed at a mine***.) The Mine

Secretary, .................................................................

Mine has been asked, by copy of this notice, to make the necessary arrangements which he will communicate to the person concerned.

(3a) (For use when the person examined is not employed at a mine***.) Arrangements for the required further examination will be as follows:

...................................................

**(4) A Periodical Certificate valid for fourteen days has been sent to the Mine

Secretary, ..............................................Mine.

This will cover the continuation of work as a miner until a final decision is intimated.

**(4a) Under the authority given by section 43 (2) of the Pneumoconiosis Act, any certificate of fitness extant in the name of the person named above is hereby suspended and no fresh certificate will be issued until a final decision is reached and intimated.

(5) A copy of this report has been sent to the Mine Secretary, ...............................

Mine.

.............

Secretary of the Bureau

NOTE FOR BUREAU GENERAL OFFICE

*If the person concerned is not employed at a mine, paragraphs (3) and (4) and the reference to the Mine Secretary in paragraph (5) must be deleted and paragraph (3a) should be completed, as the Secretary may direct, so as to show what are the arrangements for examination by the Bureau, by a Government Medical Officer, etc.

**Paragraphs (4) and (4a) should be deleted unless the official decision of the Bureau signified on the A.P. form makes the use of one or other of those paragraphs necessary. {/mprestriction}

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