Nos. 1,2,3,4 and 

17 should 

be in 

capital 

letters

 

Particulars of applicant

1.       NAME OF THE EMPLOYEE

2.       FATHER'S NAME

3.       NATIONALITY

4.       POSTAL ADDRESS

5.       Post held on the date of retirement/death.

6.       BPS _____________ date of birth _______________

7.       Date of commencement of service retirement / death/ application for pension

8.       Length of service:—

Y       M      D

From _____________ to ____________  _________________

From _____________ to ____________  _________________

From _____________ to ____________  _________________

TOTAL:

9.  Date of commencement and ending of each spell of military service, if any:—

Y       M      D

From _____________ to ____________  _________________

From _____________ to ____________  _________________

From _____________ to ____________  _________________

10.  Government under which service has been rendered, in chronological order;

Government of ____________ from __________ to __________

Government of ____________ from __________ to __________

Government of ____________ from __________ to __________

TOTAL:

11.     Class of pension or gratuity applied for _______________

12.     Average emoluments/last pay drawn of the post held on regular basis. ___________________________________

13.     Proposed gross pension/gratuity ____________________

14.     Proposed family pension __________________________

15.     Proposed value of commutation ____________________

16.     Proposed net pension ____________________________

17.     Name and branch of bank _________________________

18.     Date from which pension is to commence. ____________

                                    Official seal 

Signature of Head of Office/Department 

Name 

Designation

Section 2 

Calculation of qualifying service

1.       Total length of service as per entry 10 of Section I, non-qualifying service from ____________ to _____________.

                                                                               Period

Y       M      D

(i)      Extra ordinary leave                  ________________

(ii)     Un-authorized absence              ________________

(iii)    Spell of service not                    ________________

          qualifying for pension under rules 10, 11, 12, 13, 14 and 15 TOTAL :(i) + (ii) + (iii)

2.       Non-qualifying service:–  _________________________

          Add from to ____________________________________

                                                                               Period

Y       M      D

(i)      Periods, if any, of military service or    ____________

          war service allowed to count for pension

(ii)     Benefit of condonation of deficiency in           ____________

          total qualifying service.

Total: (i) + (ii) _____________

Total qualifying service _____________

Section 3

Calculation of average emoluments 

under Rule 34

Statement of emoluments during the last 36/12 months

Period

Duration of emoluments in months and days

Monthly rate drawn

Amount

From _______

To ________

M – D

Rs. —Ps.

Rs. — Ps.

The total emoluments for 36/12 months are __________________ Therefore, average emoluments work out to

                                                Rs. _____________ % 36/12

                        =                      Rs.       /p.m.

Section 4 

Calculation of pension

Length of total qualifying service in years

Emoluments/average emoluments/ last pay drawn

of the post held on regular basis.                    Rs. _________

Amount of gratuity (in case where qualifying

service is 5 years or more but less 

than 10 years).                                                 Rs. _________

Amount of gratuity on discharge from temporary 

service where qualifying service is 10 years or 

more but less than 25 years.                            Rs. _________

Gross pension calculated upto 30 years 

qualifying service                                            Rs. _________

                                    Total                            Rs. _________

                                    Commutation              Rs. _________

                                    Net Pension                 Rs. _________

Section 5 

Commuted value of pension

Amount of pension to be commuted Rs. ___________________

(i)      Age next birthday of 60 in case of 

superannuation (if applicable) ______________________ years ________________

(ii)     Rate of commuted value for every one rupee 

Rs. _______________

(iii)    Commuted value of pension     Rs. ________________

Section 6 

Orders of sanctioning authority

1.       The competent authority is satisfied that the service of ________________ has been satisfactory. The grant of full pension or gratuity which the administrative officer may find to be admissible under the rules is hereby sanctioned.

          The competent authority is satisfied that the service of _____________ has not been satisfactory and it has been decided that the full pension or gratuity found by the administrative officer to be admissible under the rules should be reduced by specific amounts or percentage given below:—-

          Amount or percentage of reduction in pension _________

          Amount or percentage of reduction in gratuity _________

2.       The payment of pension or gratuity may commence from ___________. Before issuing the pension payment order the officer-in-charge administration may kindly ascertain whether the last pay and no demand certificates has/have been received by him. In case the last pay certificate and/or no demand certificate has/have not been received with the pension papers, the officer-in-charge administration should issue pension payment order subject to the production of the last pay certificate and/or an undertaking at the time of first payment of pension/ gratuity, by the pensioner, or his family (in case of his death) to the effect that any demand coming to notice within a period of one year after issue of pension payment order would be recovered from him/her.

Signature ____________

Designation __________

(Director General) _____

NIO

Section 7

Certified that–

(a)      Rs. ___________ being the amount of gratuity or commutation pension have been paid to Mr./Mrs./Miss/. ____________ through cheque No. __________ dated ____________ through ____________ bank.

(b)     Instructions have been issued for payment of pension of Rs. __________ per month to Mr./Mrs./Miss/ __________ as pension through _________________ bank, under intimation to the pensioner.

                                                            ___________________

            (Signature) 

Drawing and Disbursing Officer 

(Accounts Office)

Dated: __________

Gratuity of the pensioner, or his family (in case of his death), to the effect that any demand coming to notice within a period of one year after the issue of pension payment order would be recovered from him/her.

                                                            Signature

                                                            Official Seal

                                                            Designation

                                                            (Director General, NIO)

Part – III

(For use of office to calculate pension or gratuity)

(a)      The calculations contained in the preceding pages have been checked.

(b)     Length of qualifying service accepted in years, ______

(c)      Reasons for difference, if any, between this and the length of qualifying service worked out by the office. _______________

(d)     Amount of pension ____________ Rs. ____________

(e)      Reasons for discrepancy, if any, between this amount and that calculated by the office.

(f)      Amount of family pension Rs. _________________

(g)     Reasons for discrepancy, if any, between this amount and that calculated by the office.

(h)     Amount of commutation for the pension commuted Rs. _____________

(i)      Reasons for discrepancy, if any, between this amount and that calculated by the department.

(j)      Amount of net pension Rs. ______________

(k)     The pension will commence on ______________

(l)      Allocation of the pension and commutation pension or gratuity

Pension            Gratuity or commutation pension

Government of _______________________________________

Government of _______________________________________

Government of _______________________________________

Defence estimates _____________________________________

Total _______________________________________________

(m)    Anticipatory pension of Rs. ________________ (Rupees ……………………..) per month, granted with effect from __________________ vide pension payment order No. ____________________ under rules _____________ to be adjusted in the final pension payment order.

(n)     Amount of original pension commuted Rs. ____________

(o)     Checked with the last pay certificate and no demand certificate

(p)     Pension payment order issued vide No. __________ dated ________________

—————————-

(Signature) 

Drawing and Disbursing Officer 

Accounts Office.

—————————-

(Signature) 

Administrative Officer 

Administration Section.

Instructions to be followed for timely processing of pension / gratuity cases

[see Rule 35(3)]

(1)     The administrative officer, responsible for initiating the case, should start filling in Section 2 of the working copy of the Form one year before the expected date of retirement.

(2)     Six months before the date of retirement, the employee concerned should be asked to fill in and sign Part I in a fresh copy of the Forms and submit it alongwith the required enclosures mentioned in the last Paragraph of the application for pension.

(3)     Part I of the working copy will be filled in by copying from Part I of the signed copy received back from the applicant. Similarly, Sections 2 and 4 of Part II of the signed copy will be filled in by copying from Part III of the working copy. Section I of Part II and both the Forms should then be filled in.

(4)     The signed copy should be forwarded to the administrative officer after filling in and signing Section 5 while the working copy will be retained in the initiating office as an office copy. If any extra enclosures such as list of family members, death certificate, invalid certificate, etc are required by the special nature of the case these should be attached with the Form.

(5)     After administrative officer filled in Section 6 of Part II the Form will be sent to the Drawing and Disbursing Officer (accounts office) for filling Section 7 of Part II. The Form will then be returned to administrative officer for obtaining orders of the authority.

(6)     The authority will accord sanction and send it to the Drawing and Disbursing Officer for payment action.

(7)     The Drawing and Disbursing Officer will then fill in Part III of the Form. He will also inform the employee concerned of the final amount of gratuity or commutation or pension and pension per month payable to him or her in the form of an office order copies of which will be marked to administrative officer.

(8)     On the death of pensioner, the payment of any arrears due may be made by the Drawing and Disbursing Officer, or the bank to the heirs of the deceased, without any reference to pension sanctioning authority provided they apply for such payment within one year of the pensioner's death.

Form – A

[see Rule 46]

COMMUTATION OF PENSIONES

Section I

Form of application

To,

The ……………. here enter the designation…………..and address of the accounts office

I ________________________ desire to commute Rs. ____________ of my pension of Rs. ________________ Ps. __________ a month, I certify that I have correctly furnished the following particulars as required.

1.       Date of birth.

2.       Date of retirement.

3.       Amount of pension to be commuted. ________________

4.       (a)      Portion of pension already commuted.

                   (b)        Particulars of any application for commutation of pension ever been rejected, or ever accepted/declined to accept commutation to pension on the basis of and addition of years to the actual age recommended by the medical authority.

5.       Branch and name of scheduled bank from where commutation money is to be drawn __________________

6.       If drawing pension abroad which accounts office issued the authority for payment of pension _________________

7.       If already drawing pension, quote the number and date of the pension payment order and the name of manager and branch of the bank at which drawn. __________________

8.       Without prejudice to the direction of the sanctioning authority, from what date approximately this commutation should have effect ?

9.       Station at which medical examination is preferred.

Place                                                    Signature

Date                                                    Designation

                                                            Address

(a)      To be filled only if commutation is applied for after one year of the date of retirement.

(b)     If the commutation is applied within one year of the date of retirement the accounts office will authorize the commutation admissible and the Form will not be forwarded to the authority competent to sanction pension.

Section – II

Forwarded to _______________

(here enter the designation and address of the sanctioning authority).

1.       Subject to the medical authority's recommending commutation, the lump-sum commutation payable will be as stated below:—

 

Sum payable if the commutation becomes absolute before the applicant's next birth day which falls on _________

On the basis of normal age, i.e. _______ years, Rs. ____

 

 

1. Year i.e ___ years, Rs. __

                      Plus

2. Year i.e ___ years, Rs. __

                      Plus

3. Year i.e ___ years, Rs. __

                      Plus

4. Year i.e ___ years, Rs. __

                      Plus

5. Year i.e ___ years, Rs. __

                      Plus

2.

Sum payable if the commutation becomes absolute after the

applicant's next birth day 

but before his next birth day but one.

On the basis of normal age, i.e. _______ years, Rs. ____

 

 

1. Year i.e ___ years, Rs. __

                      Plus

2. Year i.e ___ years, Rs. __

                      Plus

3. Year i.e ___ years, Rs. __

                      Plus

4. Year i.e ___ years, Rs. __

                      Plus

5. Year i.e ___ years, Rs. __

3.       The sum payable will be charged on —

                   (a)        Pension and gratuity fund of NIO's employees 

Rs. ____

          (b)     Government of Pakistan Rs. _____________

Signature of Accounts Officer/ DDO

Section – III

Administrative sanction of ______________________________ is accorded to the above commutation. A certified copy of Paragraph 2 of Section II of the Form has been forwarded to the applicant in Form-B.

Place ______________________

Date ______________________

Signature ____________________

Designation __________________

Forwarded to (here enter the designation and address of the chief medical officer) _________________ in original ____________ with the request that he wilt arrange the medial examination of the applicant by the proper medical authority as early as possible within three months from the _________________ to (here enter the date of retirement) and inform the applicant direct in sufficient time where and when he or she should appear for examination with one copy of Form-C and an extra copy of Section III of the Form.

(Signature and designation of the sanctioning authority)

Note:—This Form is to be used only if commuted value of the pension has not been applied for in the pension application.

Form-B

[see Rule 46(3)(a)]

Section – I

Forwarded to

(here enter the designation and address of the sanctioning authority).

1.       Subject to the medical authority's recommending commutation, the condition prescribed in Section II of this Form, commutation will be as stated below:—

 

Sum payable if the commutation becomes absolute before the applicant's next birth day which falls on _________

On the basis of normal age, i.e. _______ years, Rs. ____

 

 

6. Year i.e ___ years, Rs. __

                      Plus

7. Year i.e ___ years, Rs. __

                      Plus

8. Year i.e ___ years, Rs. __

                      Plus

9. Year i.e ___ years, Rs. __

                      Plus

10. Year i.e ___years, Rs. __

2.

Sum payable if the commutation becomes absolute after the applicant's next birth day but before his next birth day but one.

On the basis of normal age, i.e. _______ years, Rs. ____

 

 

1. Year i.e ___ years, Rs. __

                      Plus

2. Year i.e ___ years, Rs. __

                      Plus

3. Year i.e ___ years, Rs. __

                      Plus

4. Year i.e ___ years, Rs. __

                      Plus

5. Year i.e ___ years, Rs. __

Station ______________

Dated: ______________

Signature of Accounts Officer / DDO

Section – II

1.       The commutation for a lump sum payment of the pension is administratively sanctioned on the basis of the report of the accounts officer specified in Section I above. The table of present values, on the basis of which the calculation in the accounts officer's report have been made, is subject to alteration at any time without notice and consequently they are liable to revision before payment is made. The sum payable will be the sum appropriate to the applicant's age on his birthday next after the date on which the commutation becomes absolute or, if the medical authority directs that years shall be added to that age, to the consequent assumed age.

2.       The _________________________________________ (here enter the designation and address of the medical officer) has been requested to arrange for the medical examination and inform Mr. _______________ direct where and when he should appear for the examination. He should bring with him the enclosed From-C with the particulars required in Section I completed except for the signature.

Station ____________________

Date ______________________

Signature ____________________

Designation __________________

To,

(the name and address of the applicant)

—————————————-

—————————————-

—————————————-

Form – C

[see Rule 46]

Medical examination by the ____________________________

(here enter the authorized medical officer)

Section – I

Statement by the applicant for commutation of a portion of his pension. The applicant must complete this statement prior to his examination by the ______________________ and must sign the declaration appended thereto in the presence of the authority.

Form to be filled in by applicant

1.       State your name in full. …………………………………

          (in Block Letter)

2.       State place of birth ………………………………………..

3.       State your age and date of birth …………………………

4.       Furnish the following particulars concerning your family.

Parent's age if living and state of health

Parent's age at death if dead and cause of death

Number of brothers and sisters living, their ages and health

Number of brothers and sisters dead, their ages and cause of death.

5.       Have any of your relatives suffered from tuberculosis (Consumption, Scrofula) cancer, asthma, fits, epilepsy, insanity or any other nervous disease ?

6.       Have you ever been abroad? If yes, where and for what period and how long?

7.       Have you ever served in the Navy, Army, Air Force, or in any Government department ?

8.       Have you ever been examined,—

          (a)      for life insurance; and

                   (b)        by any Government medical officer or medical board, civil or military ? If so, state the details and with what result ?

9.       Have you ever—

                   (a)        had small pox, intermittent or any other fever, enlargementor or suppuration of glands, spitting of blood asthma, inflammation of lungs, pleurisy, heart disease, fainting attack the munatism, appendicitis, epilepsy, insanity, or other nervous disease, discharge from, or other disease of, the ear, syphilis, genorrhoes; or

                   (b)        had any other disease or injury which required confinement to bed or medical or surgical treatment; or

          (c)      undergone any surgical operation;

10.     Have you rupture ?

11.     Have you varicocels, varicose, veinsorpites ?

12.     Is your vision in each eye good ?

13.     Is your hearing in each ear good ?

14.     Have you any congenital or acquired malformation, defect or deformity ?

15.     When were you last vaccinated ?

16.     Is there any further matter concerning your health not covered by the above questions, which should be communicated to the medical authority.

DECLARATION BY APPLICANT

(To be signed in presence of the medical authority)

I declare that all the above answers, are true and correct to the best of my belief.

I will fully reveal to the medical authority all circumstances within my knowledge that concern my health and fitness.

I am fully aware that by willfully making a false statement or concealing a relevant fact, I shall incur the risk of losing the commutation I have applied for and of having my pension withheld or withdrawn.

Signed in the presence of (enter name, designation of medical authority)

Applicant's signature ____________________

Section – II

(To be filled in by the examining medical authority)

1.       Apparent age.

2.       Height.

3.       Weight

4.       Girth of abdomen at level of umbilicus.

5.       Pulse rate.

          (a)      Sitting

          (b)     Standing

6.       What is the condition of arteries ?

7.       Blood pressure:—

          (a)      Systolic

          (b)     Diastolic

8.       Is there any evidence of disease of the main organs:–

          (a)      Heart

          (b)     Lungs

          (c)      Liver

          (d)     Spleen

9.       Does chemical examination of urine shows—

          (i)      Albumen  (ii) Sugar ?

                   State specific gravity.

10.     Has the applicant a rupture ? If so, state the kind and if reducible.

11.     Describe any scars or identifying marks.

12.     Any additional information.

Section – III

I/we have carefully examined __________________ and am/are of opinion that:—

he/she is in good health and has the prospect of an average duration of life.

Is not a fit subject for commutation as he or she is suffering from_____________

Age for the purpose of commutation i.e his/her age next ……… birth day should be taken to be ________________

Station ________________

Date __________________

Signature and designation of 

examining medical authority

Schcdule-IV 

[See Rule 39 (7)]

Certificate to be appended on the bill for payment of pension

I declare that I have not received any remuneration as a regular employee under Government or any other autonomous body set up, controlled or managed by the Federal or Provincial Government, during the period for which the amount of pension claimed in this bill is due.

Note.—In the case of a pensioner permitted to draw pension after employment, the certificate should be modified accordingly.

Schedule – V 

[See Rule 40(1)]

Declaration for anticipatory pension

Whereas the (here state the designation of the officer sanctioning the advance) has consented provisionally to advance to me a pension of Rs ……………… per month and a lump sum commutation pension / gratuity in anticipation of the completion of the enquiries necessary to enable the Institute fix the amount of any pension or gratuity, I hereby acknowledge that in accepting this advance, I fully understand that my pension or gratuity is subject to revision on the completion of the necessary formal enquiries, and I undertake to raise no objection to such revision on the ground that the provisional pension or gratuity now being paid to me may exceed the pension to which I may be eventually found entitled. I further undertake to repay any amount advanced to me in excess of the pension or gratuity which I may be eventually found entitled.

Schedule-VI 

[See Rule 43(1)]

COMMUTATION TABLE

AGE NEXT BIRTHDAY

NUMBER OF YEARS PURCHASED

AGE NEXT BIRTH DAY

NUMBER OF YEARS PURCHASED

1

2

3

4

20

40.5043

51

17.6526

21

39.7341

52

17.0050

22

38.9653

53

16.3710

23

38.1974

54

15.7517

24

37.4307

55

15.1478

25

36.6651

56

14.5602

26

35.9006

57

13.9888

27

35.1372

58

13.4340

28

34.3750

59

12.8953

29

33.6143

60

12.3719

30

32.8071

61

11.8632

31

32.0974

62

11.3684

32

31.3412

63

10.8872

33

30.5869

64

10.4191

34

29.8343

65

9.9639

35

29.0841

66

9.5214

36

28.3362

67

9.0914

37

27.5908

68

8.6742

38

26.8482

69

8.2697

39

26.1009

70

7.8778

40

25.3728

71

7.4983

41

24.6406

72

7.1314

42

23.9126

73

6.7766

43

23.1840

74

6.4342

44

22.4713

75

6.1039

45

21.7592

76

5.7858

46

21.0538

77

5.4797

47

20.3555

78

5.1854

48

19.6653

79

4.9030

49

18.9841

80

4.6321

50

18.3129

SCHEDULE-VII

[See Rule 52]

CLASSIFICATION OF INJURIES

Equal to loss of limb—

          Hemiplegia without aphasia.

          Permanent use of a tracheotomy tube.

          Artificial anus.

          Total deafness of both ears.

Very Severe—

          Complete unilateral facial paralysis, likely to be permanent.

          Lesion of kidney, ureter or bladder.

          Compound fractures (except phalanges).

          Such gross destruction of soft parts as to lead to permanent disability or loss of function.

Severe and likely to be permanent—

          Ankylisis of, or considerable restriction in, the movement of one of the following joints:—

          Knee, elbow, shoulder, hip, ankle, temporo-maxillary or rigidity of the dorsilumber or cervical Sections of the spine.

Partial loss of vision of one eye.

Destruction of loss of one testicle.

          Retention of foreign bodies not causing permanent or serious sympotoms.

 

 

Schedule-VIII

[See Rule 52]

Disability pension or gratuity

CLASS OF INJURY

PENSION

GRATUITY

CHILDREN'S ALLOWANCE

 

 

 

Child without own mother

Child with own mother living

1

2

3

4

5

A

Twenty per cent of pay (Note: After death it shall devolve on widow)

Six months pay

Five per cent of pay.

Two and hall percent of pay.

B

Fifteen percent of pay.

NIL

Four per cent of pay.

Two per cent of pay.

C

Fifteen percent of pay.

NIL

NIL

NIL

Death (Special Family) Pension or Gratuity

Twenty per cent of pay.

Six months

Five per cent of pay

Two and half per cent of pay.

Schedule-IX

[see Rules 53 and 54]

PRINCIPLES AND PROCEDURE FOR DETERMINING ATTRIBUTABILITY TO SERVICE OF DISABILITY

(A)    Casualties due to wound or injury

1.       It should be established in such cases that the cause of the casualty was the result of duty in service.

2.       Where the injury resulted from the risk inherent in service, attributability will be conceded.

3.       An individual is on duty for 24 hours of the day except when on leave other than casual leave.

4.       An individual will be deemed to be in the performance of duty when—

                   (i)         he or she is physically present in his or her headquarters;

                   (ii)        he or she is travelling on leave at Government expense; and

                   (iii)       travelling to or from duty (e.g. from residence to place of duty and back but not while he or she is at his or her residence).

5.       Disability resulting from purely personal acts such as shaving or similar private pursuits would not normally be treated as attributable to service.

6.       Disability resulting from violence provoked by performance of duty will be viewed as attributable to service unless the circumstances of the case warrant a different conclusion.

7.       If circumstances are such that service played no part in the causation of disability, attritbutability will not be conceded.

          Illustration.—If a person driving a motor cycle, etc., on duty, collidies with a truck, the injury received may be attributed to service but if he is out for a walk and sustains injury from a passing truck, his case will not qualify for the concession.

(B)    Casualties due to disease

                   1.         The cause of disability resulting from a disease will be regarded as attributable to service only when it is directly due to risks which may be regarded as peculiar to the circumstances of duty in service. In determining attributability in such cases due regard should be paid to the question whether service in a particular region, or of a particular type, involved exposure to exceptional risk of contraction of, or infection by, a disease, as well as to the actual circumstances of the case.

                   2.         Attributability will not be conceded if, though contracted during the period of actual performance of duty, the disease is, in the opinion of the medical authorities concerned, due to risks which cannot be regarded as peculiar to such duty in service.

                   3.         Where a disease or its aggravation resulted from the risk of duty, attributability or aggravation will be conceded.

                   4.         All cases of tuberculosis and bronchial asthma will be accepted as attributable to or aggravated by service where the medical opinion is in favour of the acceptance.

5.       Attributability or aggravation in all cases of cardiac diseases will be determined in accordance with the guidelines mentioned at the end of this part.

6.       Where medical or other supporting documents are incomplete, cases will be dealt with on merit with due regard to medical opinion and other evidence.

Schcdule-X

[see Rule 56]

FORM – D

Form of application for injury pension or gratuity

1.       Name of applicant.

2.       Father's name.

3.       Race, sect, and caste.

4.       Residence, showing village and pergunnah.

5.       Present or last employment, including name of establishment.

6.       Date of beginning of service.

7.       Length of service, including interruptions of Years Months Days.

          Above class IV service …………………………………..

          class IV service …………………………………………..

          non-qualifying and interruptions …………………………

8.       Classification of injury.

9.       Pay at the time of injury.

10.     Proposed pension or gratuity.

11.     Date of injury.

12.     Place of payment.

13.     Special remarks if any.

14.     Date of applicant's birth by Chirstian era

15.     Height

16.     Remarks.

Thumb and finger impressions.

Thumb-fore finger-middle finger-ring finger-little finger.

17.     Date on which the applicant applied for pension.

Signature of Head of Office.

FORM – E

Form of application for family pension.

[see Rule 56(b)]

Application for an extraordinary pension (or gratuity) for the family of ……………… (here enter name of deceased employee) killed or died of injuries received, in the execution of duty.

Submitted by the ……………… (here enter name of applicant of this application).

Submitted by the             1.    Name and residence, showing village and pergunnah.

                             2.    Age.

                             3.    Height.

                             4.    Race, caste or tribe.

Description of claimant   5.    Marks of identification.

                             6.    Present occupation and pecuniary circumstances.

                             7.    Degree of relationship to deceased.

                             8.    Name.

                                         9.    Occupation and service.

                             10.  Length of service.

Description of deceased  11.  Pay when killed.

                             12.  Nature of injury causing death.

                             13.  Amount of pension or gratuity proposed.

                             14.  Place of payment.

                             15.  Date from which pension is to commence.

                             16.  Remarks.

                                    Name, date of birth by Christian era.

Name and age of 

surviving

kindred of deceased

Widows.

 

Sons.                       _______________

Daughters.

Father.

Mother.

Note.–If the deceased has left no, son, widow, daughter, father or mother surviving him the word "none" or "dead" should be entered opposite to such relative).

(Place)                                                    Signature of Head of Office.

(Date)

FORM – F

[See Rule 56(c)]

Form to be used by medical boards when reporting on injuries.

Proceedings of medical board.

CONFIDENTIAL

Proceedings of a medical board assembled by order of …………. for the purpose of examining and reporting on the present state of the injury sustained by or disease contracted by at (place of injury, etc.) on the (date of injury, etc.)

(a)      State briefly the circumstances under which the injury or disease was sustained or contracted

(b)     What is the Institute employee's present condition ?

(c)      Is the Institute employee's present condition wholly due to the injury or disease.

          If not state to what other causes it is attributable.

(d)     In the case of disease from which date does it appear that the Institute employee has been incapacitated?

The opinion of the medical board upon the questions below is as follows:—

Part A – FIRST EXAMINATION

The severity of the injury should be assessed in accordance with the following classification and details given in the remarks column below.

1.       Is the injury—                                 Yes      No

          (i)      (a) the loss of an eye or a limb.

                   (b)            the loss of more than one eye or limb.

          (ii)     more severe than the loss of an eye or a limb.

          (iii)    equivalent to the loss of the eye or a limb.

          (iv)    very severe and likely to be permanent.

          (v)     severe and likely to be permanent.

          (vi)    very severe, but not likely to be permanent.

          (vii)   slight but likely to be permanent.

2.       For what period from the date of injury—

          (a)      has the Institute employee been unfit for duty.

                   (b)        is the Institute employee likely to rejnain unfit for duty.

                               Remarks.—Here the classification above may be amplified if necessary, or details of additional injuries to the main injury may be given.

Part B. – SECOND OR SUBSEQUENT EXAMINATION

If the original degree of disability of the Institute employee has changes, in which of the above categories should it now be placed.

Remarks.— In this space additional details may be given if necessary.

Instructions to be observed by the medical board preparing the report.

1.       The medical board before recording its opinion should invariably consult the proceedings of previous medical boards, if any, as also all previous medical documents connected with the Institute employee brought before it for examination.

2.       If the injuries be more than one, they should be numbered separately; and should it be considered that, for instance, though only, severe or slight in themselves they represent together equivalent of a single very severe injury such an opinion may be expressed in the columns provided.

3.       In answering the questions in the prescribed form the medical board will confine itself exclusively to the medical aspect of the case and will carefully discriminate between the Institute employee unsupported statements and the medical documentary evidence available.

4.       The medical board will not express any opinion, either to the Institute employee examined, or in its report, as to whether he is entitled to compensation, or as to the amount of it, nor will it inform the employee how the injury has been classified.