How to write a template for employer’s opinions on work-related injuries

Work-related injury determination application form Applicant (unit): Injured employee: Relationship between the applicant and the injured employee: Applicant address: Postal code: Contact number: Date of completion: Prepared by the Ministry of Labor and Social Security Description of the form 1. Fill it out with a pen or signature pen, with neat and clear fonts. 2. If the applicant is an employer or trade union organization, stamp the official seal on the name. 3. Employees of public institutions should fill in the occupation category, and employees of enterprises should fill in the job position (or type of work) ) Category. 4. In the Injury Part column, fill in the specific part of the injury. 5. In the Diagnosis Time column, for occupational diseases, fill in according to the time of occupational disease diagnosis; for injuries or death, fill in according to the time of first diagnosis. 6. The name of occupational disease should be based on the occupational disease diagnosis certificate Or fill in the occupational disease diagnosis certificate, and fill in the time of exposure to occupational disease hazards according to the actual exposure time. If it is not an occupational disease, do not fill in. 7. After a brief description of the injury, the time and location of the accident should be written clearly, the work performed at the time, the cause of the injury and The location and extent of the injury. Occupational disease patients should write down clearly what harmful operations they are engaged in in which unit, the start and end time, and the diagnosis results. Relevant certification materials should be provided in the following cases:

(1) Injury due to performance of work duties In the case of violent injuries, a judgment or other valid certificate from the public security organ or the people's court shall be submitted;

(2) If a work-related injury determination is filed due to a casualty caused by a motor vehicle accident, a liability determination letter from the public security, traffic management and other departments shall be submitted or other valid certificates;

(3) If you are injured due to work reasons while away from work, submit a certificate from the public security department or other certificates; if an accident occurs and the whereabouts are unknown, it is determined that the death was due to work and submitted to the People's Court for declaration of death conclusion;

(4) If someone dies of a sudden illness during working hours and at his workplace or dies after ineffective rescue within 48 hours, the rescue and death certificate from the medical institution shall be submitted;

(5) If you are injured in activities such as emergency rescue and disaster relief to protect national interests or public interests, you must submit valid certificates in accordance with laws and regulations;

(6) If you are injured and disabled due to war or duty, you must change your job , demobilized soldiers whose old injuries relapse should submit the "Revolutionary Disabled Soldier Certificate" and the medical institution's diagnosis certificate for the recurrence of old injuries; if relevant certification materials cannot be provided due to special circumstances, the situation should be explained in writing. 8. Injured employees Or the relative’s opinion column should state whether they agree to apply for work-related injury determination, and whether the above filled-in content is true. 9. In the employer’s opinion column, the employer should sign whether it agrees to apply for work-related injury, whether the information filled in is true, the legal representative’s signature and the official seal of the unit .10. The labor and social security administrative department’s review materials and acceptance opinions column should be filled with the status of supplementary materials and opinions on whether to accept the materials. Name, gender, date of birth, ID number of the recognized person, work unit contact number, contact number, occupation, type of work or job Post working hours to apply for work-related injuries or deemed work-related injuries Time of diagnosis Part of injury or name of disease Time of exposure to occupational disease hazard Position Name of occupational disease Family detailed address Injury history Brief description (can attach pages): Opinions of the injured employee or relatives: Signature: Year, Month, and Date Employer’s Opinion: Legal Representative’s Signature and Seal of the Company, Year, Month, and Date Labor and Social Security Administrative Department’s Review of Materials and Acceptance Opinions: Seal, Year, Month, and Date Remarks: Template: Number: Work Injury Determination Application Form Applicant (Unit): Injured employee of XXXXX company (stamped by the company) or XX (individual): XXX Applicant’s relationship with the injured employee: Labor relations Applicant’s address: Building XX, No. XX, XXX Street, XX Road Postal code: 545XXX Contact number: 1234567 Date of filling in the form : Instructions for filling in the form issued by the Ministry of Labor and Social Security on June XX, 2006 1. Fill in with a pen or signature pen, with neat and clear fonts. 2. If the applicant is an employer or trade union organization, stamp the official seal in the name. 3. Business Unit employees should fill in the occupation category, and enterprise employees should fill in the job (or type of work) category. 4. In the column of injury part, fill in the specific part of the injury. 5. In the column of diagnosis time, for occupational diseases, fill in according to the time when the occupational disease was diagnosed; for injuries or deaths, Fill in according to the time of first diagnosis. 6. The name of the occupational disease should be filled in according to the occupational disease diagnosis certificate or occupational disease diagnosis appraisal certificate. The time of exposure to occupational disease hazards should be filled in according to the actual exposure time. If it is not an occupational disease, leave it blank. 7

.After a brief description of the injury, the time and place of the accident, the work performed at the time, the cause of the injury, the location and extent of the injury should be clearly stated. Occupational disease patients should write down the harmful operations in which unit they were engaged in, the start and end time, and the diagnosis results. .Relevant supporting materials should be provided in the following situations:

(1) If you are violently injured while performing work duties, submit a judgment or other valid certificate from the public security agency or people's court;

(2) If a work-related injury is filed due to a casualty caused by a motor vehicle accident, a certificate of responsibility from the public security and traffic management department or other valid certificates must be submitted;

(3) When you are away from work, you are injured due to work If injured, a certificate from the public security department or other certificates shall be submitted; if an accident occurs and the whereabouts are unknown, the death due to work shall be determined and submitted to the People's Court for a conclusion of death;

(4) Death of sudden illness during working hours and at the workplace Or if the person dies after ineffective rescue within 48 hours, the rescue and death certificate from the medical institution shall be submitted;

(5) If the person is injured in the activities of protecting national interests and public interests such as emergency rescue and disaster relief, he shall be treated in accordance with the provisions of laws and regulations. , submit a valid certificate;

(6) If a demobilized or demobilized soldier who is disabled due to war or duty-related injuries, and the old injury relapses, submit the "Revolutionary Disabled Soldier Certificate" and a medical institution's diagnosis of the recurrence of the old injury. Diagnosis certificate; if relevant certification materials cannot be provided due to special circumstances, the situation should be explained in writing. 8. The opinion column of the injured employee or relatives should state whether they agree to apply for work-related injury determination, and whether the above content is true. 9. Employer In the opinion column, the unit should sign whether it agrees to apply for work-related injury, whether the information filled in is true, the legal representative should sign and stamp the official seal of the unit. 10. The labor and social security administrative department should fill in the review information and acceptance opinion column, including the status of supplementary materials and whether it is accepted. Opinions. Name of the identified person XXX Gender Male Date of birth XX month 19XX ID number 45020519XX0XXX1111 Work unit XXXXX Company contact number 1234567 Contact person Work-related injury or deemed work-related injury application work-related injury accident time 200X.X.XX diagnosis time 200 A brief description of the injuries sustained at Building XX, No. XX, Street XXX, Road (can be attached): At around 10:20 a.m. on December 15, 2006, XXX, an employee in the mechanism workshop of XXXXX Company, was repairing XX machine on the workbench of the workshop. Oil, he accidentally slipped on the workbench and injured his elbow. He was sent to Liuzhou City XX Hospital for treatment. The hospital diagnosed him as: left elbow injury. Opinion of the injured employee or relatives: Agree to apply for work-related injury determination. The above information is true. Signature: XXX year month day Employer's opinion: Agree to apply for work-related injury identification, the above filled content is true Signature of the legal representative: XXX unit seal year month day Labor and Social Security administrative department review information and acceptance opinions: Seal year month day Remarks: Attachment 2: Administrative approval flow chart Flow chart for enterprise employee work-related injury identification Acceptance: Person in charge of the approval window position: Contact information: 2801532 Review and investigation and verification: Person in charge of the approval window position: Contact information: 2801532 Approval: Person in charge of the approval window position: Contact information: 2801532 Issuance conclusion: Approval window position person in charge: Contact information: 2801532 Liuzhou Municipal Labor and Social Security Bureau Administrative Approval Items Legal Basis Manual Approval Item Name: "Identification of Work-related Injuries for Enterprise Employees" Item Category: Administrative Approval Document Number: Date of Compilation: 2009- 3-16 Review and on-site verification of the work-related injury determination conclusion letter: According to the review needs, at least two staff members can be assigned to the site to investigate and verify the accident injury.

(60 days) If the acceptance conditions are met, the "Acceptance Notice" 》(Issue a written notice of acceptance) If the applicant does not meet the acceptance conditions, a written notice of non-acceptance will be issued. Preliminary review: the materials are legal and complete. The business window will review the application materials and sign the review opinions. (Within 4 days) Review materials: The handling personnel will review whether the materials are complete (and submit them within 3 days)

If the submitted application materials (see attachments and instructions for filling out the form) are incomplete, a "Notice of Supplementary and Corrected Materials" will be issued to the applicant, returned to the applicant, and the applicant will be notified at one time of the information that needs to be submitted during the application to apply to the labor and social security administrative department. The time limit for applying for work-related injury recognition (30 days for the employer, 1 year for the individual or family member) starts from the date when an employee is injured in an accident or is diagnosed with an occupational disease and is identified as an occupational disease, and the materials are compiled and archived.