Tisch
Xxx labor ability appraisal committee:
Injury * * * Suffering from * * *: Gender: Age:
ID number: Time of injury:
Injured position: industrial injury certificate number:
Personal social insurance number: unit:
Apply now: appraisal.
Signature of the applicant: * * or company seal * * *
date month year
extreme
Applicant: Wu Jiren, an injured worker, male, 59 years old, an on-the-job employee of Qingjiang Central Health Center in Bazhou District, Bazhong City. I was unfortunately injured at work on June 22, 2008 10, and was diagnosed with mild concussion by Bazhong People's Hospital. Left occipital scalp hematoma; Left eye * * *1* * * * * 2 * * * * 3 * * * ball blunt file; C3-C6 intervertebral disc displacement. In May 2009, in the First Affiliated Hospital of Chongqing Medical University, he was diagnosed with ***4*** left arm plexus nerve injury and left upper limb muscle strength grade III. On July 6, 2009, it was recognized as a work-related injury by Bazhong Labor and Social Security Bureau. After being treated by drugs and physical therapy in Bazhong People's Hospital, the First Affiliated Hospital of Chongqing Medical University and Qingjiang Central Health Center, there are still the following sequelae: amnesia and abnormal body sensation, mainly manifested as forgetfulness of *** 1*** numbers and names. ***2*** Cervical spine movement is limited; ***3***, the activity of both upper limbs is limited, and it is impossible to lift, abduct and stretch back; ***4***, the right upper limb continues to be numb, with severe pain, muscle weakness and inability to bear weight. In view of the above situation, I can't take part in normal work and can't take care of myself most of the time. I hereby apply to the members of the Labor Ability Appraisal Committee of Bazhong Labor Bureau, requesting to give the applicant the labor ability appraisal. Submitted to the members of Bazhong Labor Ability Appraisal Committee.
Worker injured at work: Wu Jiren * * Tel: 5788784 * * Family member: Yuan.
Legal person of Qingjiang Central Health Center: Li * * * Tel:13330617185 * * *
Press release issued on 29 July 2009
Tisso
Shenzhen Labor Ability Appraisal Committee: injured person: ID number: injured part: personal social security number: now applying for work: unit: appraisal. Signature of the applicant: * * or company seal * * year, month and day.
First Alliance Social Security
Gender:
Age:
Injury time:
Industrial injury certificate number:
Description of application: 1. Submit four recent one-inch bareheaded photos of the appraiser at the time of application; □ A printed copy; □ 2. Original and photocopy of work-related injury certificate
Bumen
3. The original and photocopy of the ID cards of the applicant and appraiser 1 copy; □
Step 4 save the roots
All original medical records related to work-related injuries; □ One copy and two copies; □
5, the first review appraisal should provide all the original appraisal conclusion.
6. The identification of the recurrence of old injuries must provide: ① Introduction of work-related injury departments.
Letter; (2) the conclusion of the first work-related injury appraisal; ③ All medical records related to work-related injuries; □7. In case of illness * * * and non-work-related injury, the power of attorney of the unit or the certificate of termination of the labor contract of * * * shall be provided; □
Choice of delivery mode of labor ability appraisal conclusion
Name of organization: mailing address: appraiser: mailing address: Remarks: Note: If the applicant fails to effectively deliver the appraisal conclusion due to a mistake in filling in or an unknown address, it shall be deemed that the appraisal conclusion has been delivered. Signature of the applicant: official seal: Remarks: (1) Within 20 to 40 days from the date of appraisal, go to the 4th floor of Haitian Building, Caitian South Road, Futian District, Shenzhen, and collect the appraisal conclusion from the business window of the office of Shenzhen Labor Ability Appraisal Committee. (two) if it is not received within the time limit, it shall be deemed to have been served; (3) If someone else is entrusted to collect it, a power of attorney and a valid certificate shall be issued. Signature of the applicant: official seal: * *: * *: * * *:
□ pick it up yourself.
□ Shenzhen application for labor ability appraisal
Shenzhen Labor Ability Appraisal Committee: injured person: ID number: injured part: personal social security number: now applying for work: unit: appraisal. Signature of the applicant: * * or company seal * * year, month and day.
Second joint application
Gender:
Age: Injury Time: Work Injury CertificateNo.:
Application description:
1. Submit 4 recent one-inch bareheaded photos of the appraiser when applying; □ A printed copy; □
2. Original and photocopy of work-related injury certificate
3. The original and photocopy of the ID cards of the applicant and appraiser 1 copy; □
4. All original medical records related to work-related injuries; □ One copy and two copies; □
5, the first review appraisal should provide all the original appraisal conclusion.
6. The identification of old injury recurrence must provide: ① Letter of introduction from the industrial injury department; (2) the conclusion of the first work-related injury appraisal; ③ All medical records related to work-related injuries; □7. In case of illness * * * and non-work-related injury, the power of attorney of the unit or the certificate of termination of the labor contract of * * * shall be provided; □
Choice of delivery mode of labor ability appraisal conclusion
Name of unit: mailing. Mailing address: appraiser: Mailing address: Note: If the applicant fails to effectively deliver the appraisal conclusion due to wrong filling or unknown address, it shall be deemed that the appraisal conclusion has been delivered.
Signature of applicant: company seal: addressee