FORM 2 [reg.4] EMPLOYEES’ COMPENSATION …

1 -1 -FORM 2 EMPLOYEES COMPENSATION ordinance (CAP. 282)SECTION 15 NOTICE BY EMPLOYER OF THE DEATH OF AN EMPLOYEEOR OF AN ACCIDENT TO AN EMPLOYEE RESULTINGIN DEATH OR INCAPACITYI mportant Notes(1)To be completed and returned in DUPLICATE to the Commissioner for Labour -(a)WITHIN 7 DAYS of the accident in the case of death; or(b)WITHIN 14 DAYS of the accident in the case of injury; or(c)WITHIN such period of time as required by the Commissioner for Labour.(2)An employer who fails to give notice as required or who gives any false or misleading information to theCommissioner for Labour may be prosecuted.(3)Part I must be completed for each employee. Part II is to be completed only if the accident occurred on aconstruction site.(4)If more than one employee was injured or died as a result of an accident, please complete a separate formin duplicate for each employee.(5)Please 9 in the appropriate box.(6)Please read the instructions carefully before completing this 27(a)(S)( )[ ]-2 -FORM 2 EMPLOYEES COMPENSATION ordinance (CAP.)

2 282)SECTION 15 NOTICE BY EMPLOYER OF THE DEATH OF AN EMPLOYEEOR OF AN ACCIDENT TO AN EMPLOYEE RESULTING IN DEATH OR INCAPACITYTo the Commissioner for LabourI declare that the information given in this form is, to the best of my knowledge, true and :(for and on behalf of the employer)Name (in block letters) :Position :Sole proprietorPartnerManagerOfficerDate :Chop of Company(Note 1) of the employeeName of employee (Surname first)Identity Card/Passport of Birth / / Day/Month/YearSex Male FemaleOccupationAn apprentice Yes of employerName of employing company/personBusiness Registration Certificate No.(Note 2)Telephone of principal contractor/holding company(Note 3)Name of principal contractor/holding companyBusiness Registration Certificate of accidentDescribe how the accident happened and state what the employee was doing at the time(Note 4)State whether the accidentoccurred in the course of work Yes NoDate of accident / / Day/Month/YearTime of of accident Death InjuryAddress of the place of accidentName of hospital/clinic where the employee received treatment Part I -3 of insurance(Note 5)Name and address of insurance company at the time of accident (Please refer tothe insurance policy)Policy of earnings of the employeeAverage number of working days per month22242630 Others (please specify)Rest day is(a)not paidpaid(b)not fixedfixed on (Day of week)Details of earnings per month for the month immediately preceding the date of accident.

3 (Note 6)(a)Basic salary/wages$ / month(b)Food allowances/value of free food provided by employer $ / month(c)Other items : $ / month (please specify)Total (a) + (b) + (c)$ / monthAverage monthly earnings of the employee for the past 12 months (or total period of employment, if less than 12 months)preceding the accident were$ / accident (to be completed where accident results in death)Whether police was notifiedYes(name of police station)Name and address of next-of-kin of the deceasedemployeeRelationship with thedeceased employeeNoTelephone settlement (to be completed only where the injury results in temporary incapacity for not more than 7days and no permanent incapacity, and the employer and employee have chosen to directly settle theemployees COMPENSATION claim)Period of sick leavefrom / / to / / Day / Month / Year Day / Month / Year / / to / / Day / Month / Year Day / Month / YearTotal number of sick leave days.

4 DaysAmount of COMPENSATION :$paidto be paid on / / Day / Month / Year-4 of accident (tick one box)The accident occurred in (Note 7)Construction siteShipyardManufactoryOthers01 Building worksite04 Floating vessel07 Production area11 Container yard0203 Civil worksiteRenovation/repair of existing buildings0506 Non-floating vesselMaintenance workshop080910 Maintenance workshopLoading/unloading areaStorage area1213 Catering establishmentPlease specifyActivity carried out on the site at the time of accident(Note 8) of injury(Note 9)Describe the nature of injuryIndicate nature of injury (tick one box) 01 Abrasion06 Contusion &bruise11 Electric shock16 Poisoning02 Amputation07 Concussion12 Fracture17 Irritation03 Asphyxia08 Laceration and cut13 Puncture wound18 Nausea04 Burn (heat)09 Dislocation14 Sprain & strain19 Multiple injuries05 Burn10 Crushing15 Freezing20 Others (please specify)

5 Part of body injured (tick one box) HeadNeck & TrunkUpper LimbsLower Limbs21 Skull/scalp31 Neck41 Finger51 Hip61 Multiple locations22 Eye32 Back42 Hand/palm52 Thigh (please specify)23 Ear33 Chest43 Forearm53 Knee24 Mouth/tooth34 Abdomen44 Elbow54 Leg25 Nose35 Trunk45 Upper arm55 Ankle26 Face36 of accident (tick one box)(Note 9)01020304 Trapped in or between objectsInjured whilst lifting or carryingSlip, trip or fall on same levelFall of person from height*metres* distance through which person fell05060708 09 Striking against fixed or stationary objectStriking against moving objectStepping on objectExposure to or contact with harmful substanceContact with electricity or electric discharge1011121314 Trapped by collapsing or overturning objectStruck by moving or falling objectStruck by moving vehicleContact with moving machinery or object being machinedDrowning151617 Exposure to fireExposure to explosionOthers (Please specify)-5 involved, if any (tick one or more boxes)(Note 9)010203 Equipment for lifting/conveyingPortable power or hand toolsOther machinery, please specify:Type :Part causing injury.

6 (a)prime mover(b)transmission part(c)working part040506 Material/product being handled or storedLadder or working at heightSewage, manhole or other confined space070809 Movable container or package of any kindFloor, ground, stairs or any working surfaceGas, vapour, dust or fume101112 Electricity supply,wiring apparatusor equipmentVehicle or associated equipment or machineryOthers (Please specify)Describe briefly the agents you have indicated(Note 9) (to supplement the descriptions given above, if considered necessary)For official use by End of Part I -6 - Part II (To be completed if the accident occurred on a construction site) of work performed by the employee at the time of accident (tick one box)01 Concreting07 Painting13 Trench work19 Slope work02 Woodworking08 Plastering14 Gas pipe fitting20 Others03 Glazier work09 Arc/gas welding15 Water pipe fitting (please specify)04 Reinforcement bar bending10 Formwork erection16 Electrical wiring05 Bamboo scaffolding11 Brick laying17 Material handling06 Tubular scaffolding12 Caisson work18 Lift installationWhereabouts on the site such work was involved, if any (tick one or more boxes)(Note 10)01 Skip/material hoist06 Hydraulic crane11 Bar bender02 Passenger hoist/builders lift07 Suspended working platform12 Concrete mixer03 Tower crane08 Boatswain s chair13 Air compressor/receiver04 Mobile crane09 Pile driver14 Others (please specify)05 Lorry-mounted crane10 Boring or construction machinery involved, if any (tick one box)01 Dump truck04 Bulldozer07 Others (please specify)

7 02 Loader05 Grader03 Excavator06 Compacting roller End of Part II -7 -Explanatory NotesNote 1:The signature and company chop which appear in both copies of Form 2 submitted to theCommissioner for Labour should be in the 2:If the Business Registration Certificate No. is not available, the Identity Card No. of theemploying person should be 3:Section C on particulars of principal contractor/holding company should be completed only whenthe employer is either (a)a subcontractor; or(b)a subsidiary of a holding company within the meaning of the Companies ordinance ( ) and which is covered by and specified in the insurance policy taken out by the group ofcompanies to which it 4:Describe how the accident happened, state what the employee was doing at the time and givedetails of how the accident happened, what work was the injured doing, what factors (directlyand indirectly) leading to the accident, and how he was injured, 5:The name and address of the insurer as appeared on the insurance policy, instead of those of thebroker or agent, should be entered 6:Earnings include (a)cash wages.

8 (b)the value of any privilege or benefit which can be estimated in cash, food, fuel orquarters supplied to the employee if, as a result of the accident, he is deprived of any ofthem;(c)overtime or other special remuneration for work done, whether in the form of bonus,allowance or otherwise, if it is of a constant nature; and(d)customary remuneration for intermittent overtime, casual payments of a non-recurrent nature, the valueof travelling allowances or concession and the employer s contributions to provident funds arenot 7:Construction SiteBuildingworksite: site for building substructure, superstructure, worksite: site for building roads, bridges, of existing buildings: internal or external renovation, repairing, painting orexternal wall cleaning, etc. (Note: Fitting-out in new buildings should be regarded as a buildingworksite.).ShipyardFloating vessel: ship building or repairing conducted on floating shipyard or floating vessel: ship building or repairing conducted on slipway or workshop: maintenance workshop of the shipyard where parts of ships aremachined, repaired or area: production workshop or any location where actual production is being workshop: maintenance workshop of the manufactory where machinery parts aremachined, repaired or area: location inside the manufactory assigned for loading and unloadingactivities including cargo area: location inside the manufactory used for storage -OthersContainer yard: the location where container handling, stacking and maintenance work, etc.

9 Arebeing carried 8:Please briefly describe the main function of the workplace at the time of the 9:Please give details on the injury sustained, while working on a working platform, anemployee twisted his ankle and fell 3 m onto the the above example, the following boxes in sections J, K and L should be marked zIn section J Nature of injury: Sprain & strain (box 14).zIn section J Part of body injured: Ankle (box 55).zIn section K Type of accident: Fall of person from 3 m (box 04).zIn section L Agents involved: Ladder or working at height (box 05).zIn the description of the agents indicated: A platform constructed of a plank whichmeasured 5 m long by 2 m wide and by 5 mm 10:If none of the machinery provided is suitable, please tick box 14 and specify the name of themachinery or briefly describe the type of machinery Information on Accidents on Construction Sites Explanatory Note: This is not a statutory form required to be submitted under the Employees COMPENSATION ordinance for reporting accident.

10 However, the co-operation of employers is sought to complete Sections I to V below for accidents occurred on construction sites. The supplementary information will be used for the purpose of accident analysis within Government and by the public bodies concerned. of Worksite/ Commencement of : Construction Work Expected Completion Date: / Contractor Name: Site Address: Contract No. (if available): Date of Accident: Contact Telephone: _____ Chop of Company II. Particulars of Project(A)Nature of Project Civil Engineering Superstructure Maintenance and Repair(B)Private Project Yes NoIf Yes, please give name and contact telephone no. ofIf No, please indicate below the type of authorized person or project managerpublic works/government project Name: _____( Position: _____ )Tel. No.: _____(C)Public Works or Government Project 01 Architectural ServicesDepartment 02 Buildings Department 04 Drainage Services Department 05 Electrical & MechanicalServices Department 06 Highways Department 08 Water Supplies Department 09 Housing Department 12 Airport Authority Hong Kong 13 Agriculture, Fisheries &Conservation Department 14 Environmental ProtectionDepartment 15 Home Affairs Department 18 Food & Environmental HygieneDepartment 19 Civil Engineering & DevelopmentDepartment 20 MTR Corporation Limited 99 Others (please specify) of Place of Fall (If Injured by Fall from Height) 01 Bamboo scaffold 04 Working platform/falsework 07 Ladder 02 Fragile structure 05 Unfenced edges & lift shaft opening 08 Others 03 Material hoistway 06 Unfenced/insecurely covered 01 Chinese 04 Indonesian 07 Pakistani 10 Other Asian 02 Filipino 05 Japanese 08 Thai 11 Others 03 Indian 06 Nepalese 09 WhiteV.